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MENTAL  DEFICIENCY 

(AMENTIA) 


Digitized  by  tine  Internet  Arciiive 

in  2010  witii  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/mentaldeficiencyOOtred 


TYPES   OF   BRAIN   CELLS  OCCURRING   IN   AMENTIA. 

(Drawn  as  seen  under  jV  inch  oil-immersion  lens.) 


k/y 


Fig.  I. 


Fig.  2. 


Fig.  X. 


"^^aig*- 


Fig.  4. 


Fig.  5. 


Fig.  6. 


Fig. 


Fig.  S. 

A.  F.  Tredgold  del.  igoS. 


Fig.: 

*!•- 

Fig. 

2.- 

Fig. 

3-" 

Fig. 

4-- 

Fig. 

5-" 

Fig. 

6.- 

Fig. 

7-- 

Fig. 

S.- 

-Incompletely  developed  nerve  cells  (neuroblasts),  from  layer 
of  small  pyramids  of  frontal  cortex. 

-Incompletelj'  developed  nerve  cell,  from-  middle   pyramidal 
layer  of  motor  cortex. 

-Neuroglia  cell ;  from  a  case  of  sclerotic  amentia. 

-Incompletely  developed  nerve  cells,  from  layer  of  middle  pyra- 
mids of  frontal  cortex. 

-Atrophied  and  distorted  medium  pyramidal  nerve  cell  ;  frcm 
a  case  of  sclerotic  amentia. 

-Medium  pyramidal  cell  from  frontal  cortex,  undergoing-  sub- 
acute degeneration  ;  from  a  case  of  secondarj-  amentia. 

-Medium  pyramidal  cell  from  frontal  cortex,  undergoing  chronic 
pigmentary  atrophy. 

-Pigmented  cell  of  hippocampus  ;  from  a  case  of  amentia  v.ith 
epileps}'. 


Frontispiece.  ] 


MENTAL  DEFICIENCY 

(AMENTIA)     . 


1 1  f '  ,M  ' 


A.    F.    TREDGOLD 

L.R.C.P.    LoND.,    M.R.C.S.    Eng.,    F.R.S.    Edin. 

CoxsuLTixG  Physician  to  the  National  Association  for  the  Feeble- Minded,  and 

TO  THE  Littleton  Home  for  Defective  Children  :   Lecturer  at  the  Medical 

Graduates'  College,  London  ;    Formkrly  Medical  Expert  to  the  Royal 

Commission  on  the  Feeble-Minded  ;    Research  Scholar   in    Insanity 

and  Neuropathology  of  the  London  County  Council  and  Assistant 

IN   THE    CLAYBURY    PATHOLOGICAL     LABORATORY  ;     LATE     RESIDENT 

Clinical  Assistant  in  the  Northumberland  County  Asylum, 

ETC 


SECOND   EDITION 

REVISED  AND  ENLARGED 
(reprinted) 


NEW     YORK 
WILLIAM    WOOD    &    COMPANY 

MDCCCCXV 


PRINTED  IN   ENGLAND  BV   BAILLIERE,   TINDALL  AND  COX 
8,    HENRIETTA  STREET,   COVENT  GARDEN,   LONDON 


/9/S 


TO 

ALL  THOSE  PERSONS  OF  SOUND  MIND 

WHO    ARE    INTERESTED    IN    THE    WELFARE 
OF    THEIR    LESS    FORTUNATE    FELLOW-CREATURES 


PREFACE  TO  SECOND  EDITION 

The  sale  of  the  whole  of  the  first  edition  of  this  book,  its  very 
favourable  reception  by  the  Press,  and  the  kind  letters  regarding 
it  which  I  have  received  from  many  well-known  members  of  the 
profession,  lead  me  to  think  that  it  has  filled  a  want  in  the  literature 
of  psychiatry,  and  embolden  me  to  publish  a  second  edition. 

The  present  edition  has  been  thoroughly  revised,  many  chapters 
entirely  rewritten,  and  a  new  one  added  dealing  with  mental  tests 
and  case-taking;  whUst  the  passing  of  the  Mental  Deficiency  Bill 
has  enabled  me  to  give  an  account  of  those  changes  in  the  law  of 
England  which  cannot  fail  to  bring  mental  defectives  into  close 
relationship  with  the  medical  profession. 

The  ramifications  of  the  subject  of  mental  deficiency  are  now  so 
numerous  and  its  literature  so  extensive,  that  it  is  impossible  to 
refer  to  all  the  work  which  has  been  done  during  the  past  five  years. 
I  hope,  however,  that  nothing  has  been  omitted  from  this  edition 
which  is  original  and  of  practical  importance,  and  I  trust  that  it 
will  still  continue  to  be  of  use  to  all  those  who  are  called  upon  to 
deal  with  this  class. 

I  gratefully  acknowledge  my  indebtedness  to  my  friend  Dr.  R. 
Langdon  Down  for  his  kindness  in  reading  through  several  chapters, 
and  for  much  valuable  criticism  and  advice. 

A.  F.  TREDGOLD. 

25,  New  Cavendish  Street, 
London,  W. 

January,  iqi  \. 


PREFACE  TO  FIRST  EDITION 

During  the  past  few  years  the  subject  of  mental  deficiency  has 
evoked  a  large  amount  of  attention  from  many  prominent  persons 
interested  in  social  and  philanthropic  questions.  To  members  of 
the  medical  profession  in  particular  it  is  one  of  much  importance, 
on  account  of  their  responsible  duties  connected  with  its  diagnosis, 
with  the  treatment  and  training  of  these  patients,  and  their  ex- 
amination and  certification  as  to  fitness  for  special  classes  and 
schools,  training-homes,  and  asylums.  And  there  is  no  doubt  that 
with  new  legislation,  which  cannot  now  long  be  delayed,  these 
duties  and  responsibilities  will  be  considerably  increased. 

For  these  reasons  I  venture  to  hope  that  the  account  which  I 
have  attempted  to  give  in  these  pages  regarding  the  incidence, 
causation,  pathology,  -mental  and  physical  characteristics,  social 
relationship,  diagnosis,  prognosis,  and  treatment  of  persons  suffer- 
ing from  mental  deficiency,  will  be  found  to  justify  its  publication. 

To  a  great  extent  this  account  is  based  upon  observations  and 
researches  which  I  have  been  making  for  close  on  ten  years,  but 
I  have  also  made  full  use  of,  and  frequent  reference  to,  the  writings 
of  many  other  workers  in  this  "field.  Valuable  help,  permission  to 
examine  cases,  and  make  use  of  notes  and  illustrations,  has  been 
generously  accorded  me  from  many  quarters.  In  particular  I  would 
like  to  take  this  opportunity  of  gratefully  acknowledging  my 
indebtedness  to  the  members  of  the  Asylums  Committee  of  the 
London  County  Council;  also  to  Dr.  Francis  Warner,  London; 
Dr.  G.  A.  Sutherland,  London;  Dr.  John  Thomson,  Edinburgh; 
Dr.  F.  W.  Mott,  F.R.S.,  Pathologist  to  the  London  County  Asylums 
and  Director  of  the  Pathological  Laboratory;  Dr.  R.  R.  Alexander 
and  Dr.  P.  Bailv,    Hanwell   Asylum;  Dr.  W.  J.  Seward,  Colney 


X  Preface  to  First  Edition 

Hatch  Asylum;  Dr.  J.  M.  Moody,  Cane  Hill  Asylum;  Dr.  Robert 
Jones,  Claybury  Asylum;  Dr.  T.  W.  McDowall,  Morpeth  Asylum; 
Dr.  F.  R.  P.  Taylor  and  Dr.  C.  A.  Marsh,  formerly  of  Darenth 
Asylum;  Dr.  C.  Caldecott,  Earlswood  Training  Institution;  and 
Dr.  R.  Langdon  Down,  Normansfield  Training  Institution. 

The  greater  portion  of  the  microscopical  work  was  carried  out 
in  the  Clayburv^  Pathological  Laboratory,  during  my  two  years' 
tenure  of  the  London  County  Council  Research  Scholarship  in 
Insanity  and  Neuropathology;  and  to  the  unequalled  advantages 
which  this  scholarship  afforded  for  clinical  and  pathological  research 
in  these  fields  of  medicine  I  desire  to  pay  a  grateful  tribute. 

Finally,  I  wish  to  express  my  indebtedness  to  the  recently  issued 
voluminous  Reports  of  the  Royal  Commission  on  the  Care  and 
Control  of  the  Feeble-Minded.  Of  the  mass  of  information  contained 
in  these,  regarding  the  number  and  condition  of  the  mentally 
deficient  population  of  this  country,  I  have  made  full  use.  It  is 
necessary,  however,  to  add  a  word  of  explanation  with  regard  to 
statistics.  Under  the  term  "  mentally  defective  "  the  Commis- 
sioners include  sane  epileptics.  Since,  in  my  opinion,  these  should 
not  rightly  be  classed  as  aments,  I  have  considered  it  advisable  to 
make  independent  calculations  from  the  original  returns — hence 
the  slight  discrepancy  between  the  two  sets  of  figures. 

A.  F.  TREDGOLD. 

September,   1908. 


TABLE  OF  CONTENTS 


PAGES 

PREFACES        ----.-.  vii-x 


CHAI'TER 

I.  THE  NATURE  OF  MENTAL  DEFICIENCY  -  -  1-9 

Use  of  the  term  "  mental  deficiency."  Range  of  intellectual 
capacity.  Normal  and  abnormal  variations.  Fallacy  of  peda- 
gogical standard.  Essential  function  of  mind  is  ability  to 
maintain  existence.  Absence  of  this  constitutes  abnormality. 
Objections.  Survival  in  relation  to  the  environment.  Defini- 
tion. 

II.  INCIDENCE     -------         10-19 

Difficulty  of  enumeration.  Investigations  of  the  English  Royal 
Commission  of  1904.  The  number  of  aments  in  England  and 
Wales.  Incidence  of  the  three  degrees  of  amentia.  Incidence 
of  amentia  relative  to  insanity.  Location  of  aments  in  England 
and  Wales.     Incidence  with  regard  to  sex. 

III.  CAUSATION     --,----         20-69 
General  Considerations: 

The  relative  influences  of  inheritance  and  environment.  The 
nature  of  the  germinal  defect.  Its  origin.  Its  mode  of 
transmission.     Amentia  due  to  external  causes. 

The  Causal  Factors  of  Amentia: 

A.  Indicative  of,  or  producing,  germ  variation  : 

Neuropathic  inheritance.  Alcoholism.  Tuberculosis. 
Syphilis.     Consanguinity.     Age  of  parents. 

B.  Causing  Somatic  Modifications  : 

Acting  before  Birth. — Abnormal  conditions  of  the  mother 
during  gestation.  Physical.  Mental.  Illegitimacy. 
Maternal  impressions. 

Acting  during  Birth. — Abnormalities  of  labour.  Primo- 
geniture.    Premature  birth. 

Acting  after  Birth. — Traumatic.  Toxic.  Convulsive. 
Nutritional. 

Etiological  Factory  in  regard  to  Local  Variations  of  Incidence. 

Illustrative  Family  History  Charts. 


xii  Table  of  Contents 

CHAPTER  PAGES 

IV.  PATHOLOGY  .  .  .  -  _         70-88 

The  development  of  the  norqaal  brain. 
Pathology  of  Amentia: 

The  essential  basis  of  amentia.    - 
Histology: 

Cells  of  the  cortex  cerebri.  Situation  of  the  cellular  changes. 
Fibres.  Neurogha.  Vessels.  The  Tiistolog}'  of  secondary 
amentia. 

Morbid  Anatomy: 

Gross  developmental  anomahes  and  pathological  lesions. 
Hemiatrophy.  ^Microgyria.  Porencephaly.  Deficiency  of 
internal  structures.  Hydrocephalus.  Encephalitis  and 
meningo-encephalitis.     The  skull. 

V.  CLASSIFICATION       ------         89-9S 

Division  of  amentia  into  forms,  degrees,  and  clinical  varieties. 

Forms  : 

Primary.     Secondary.     Delayed  primary  or  developmental. 

Degrees  : 

Feeble-mindedness  (children  and  adults).  Imbecihty.  Idiocy. 
"  Moral  Imbecihty."     Definitions. 

Clinical  Varieties: 

Of  primary  amentia  :  Simple,  Microcephahc,  Mongohan. 
Of  secondary  amentia  :  Amentia  due  to  cerebral  disease,  amentia 
due  to  defective  cerebral  nutrition. 

Table  of  Classific.a.tion. 

VI.  NEURO-PHYSIOLOGY  AND  PSYCHOLOGY  -  -       99-136 

Sensation  : 

Its  importance  to  mentality.  Taste.  Smell.  Vision.  Hearing. 
Cutaneous.     Muscle.     Organic . 

Cerebration  : 

Perception.  Attention.  Association.  Memory.  Ideation, 
imagination,  and  thought.  Judgment  and  reasoning.  Voli- 
tion.    Temperament.     Emotion.     Sentiment. 

Action  : 

Varieties  of  movement.  Deficient.  Excessive.  Inco-ordinate. 
Speech.    Word  blindness  and  word  deafness.    ^lirror-writing. 

Vll.  PHYSICAL  CHARACTERISTICS  OF  AMENTIA    -  -     137-155 

Prevalence  of  physical  defects  in  amentia.  Stigmata  of 
degeneracy. 

Anomalies  of  Anatomical  Development: 

A.  Nervous  system.  B.  Special  sense  organs.  C.  Osseous. 
D.  Muscular  and  cutaneous.  E.  Circulatory  and  respiratory. 
F.  AUmentary.     G.  Urinary  and  generative. 


Table  of  Contents  xiii 

CHAPTER  PAGr-;S 

PHYSICAL  CHARACTERISTICS  OF  AMENTIA   {continued)— 
Anomalies  of  Physiological  Function: 

Of  special  organs  and  of  tissues  in  general.  Mortality. 
Age  periods  of  death.     Causes  of  death,  with  table. 

VIII.  FEEBLE  -  MINDEDNESS       IX      CHILDREN       (MENTALLY 

DEFECTIVE  CHILDREN)   -  -  -  -     156-172 

Introductory  account,  with  early  inquiries  into  number  and 
condition.  Definition.  Special  schools  and  classes.  In- 
quiries of  Royal  Commission  of  1904.  Number.  Relative 
incidence  in  different  areas  of  the  United  Kingdom.  Rela- 
tive incidence  in  town  and  country.     Sex. 

Description  : 

Physical.  Nervous.  Mental.  Scholastic,  The  three  grades 
of  defect.     Varieties  of  mentally  defective  children. 

IX.  FEEBLE-AIINDEDNESS  IN  ADULTS        -  -  -     173-188 

Definition.     Number.     Sex. 

Description  : 

Physical  and  mental  characteristics.  The  "  stable "  type. 
The  "  unstable  "  type.     Examples. 

X.  IMBECILITY  -..--.     189-194 

Definition.     Number.     Sex. 

Description: 

Physical.     Mental  and  nervous.     Examples. 

XL  IDIOCY  -  -  -  -  -  -  -     195-201 

Definition.     Number.     Sex. 

Description: 

Partial  or  Incomplete  Idiocy. — Physical.    Mental  and  nervous. 

Apathetic  and  excitable  idiots.     Examples. 
Absolute  or  Complete  Idiocy. 

XII.  CLINICAL  VARIETIES  OF  PRIMARY  AMENTIA  -     202-223 

Division  of  primary  aments  into  varieties. 

Microcephalics  : 

Introductory  account  and  number.  Causation.  Pathology. 
Relation  of  brain  weight  to  intellect.  Physical,  mental, 
and  nervous  condition.     Examples. 

Mongolians  : 

Introductory  account  and  number.  Causation.  Pathology. 
Description  of  physical,  mental,  and  nervous  characteristics. 

The  Complications  of  Pri>l\ry  Amentia: 

Epilepsy.  Paralysis.  Hydrocephalus.  Porencephalus.  Sclero- 
sis.     Deaf-mutism. 


xiv  Table  of  Contents 

CHAPTER  PAGES 

XIII.  CLINICAL  VARIETIES  OF  SECONDARY  AMENTIA  -     224-301 
Clinical  differences  between  primary  and  secondary  amentia. 

Section  I.  Amentia  due  to  Gross  Cerebral  Lesions: 
Toxic,  inflammatory,  and  vascular  amentia. 

(a)  Porencephalic. 

(b)  Sclerotic. 

(c)  Hydrocephalic. 

(d)  Syphilitic. 

(e)  Amaurotic. 

Section  II.  Amentia  due  to  Defective  Cerebral  Nutri- 
tion: 

1.  Epileptic  and  eclampsic  amentia. 

2.  Cretinism:  Endemic,  sporadic. 

3.  Amentia  due  to  malnutrition. 

4.  Amentia  due  to  isolation  and  sense  deprivation. 


XIV.  IDIOTS  SAVANTS     ------     302-312 

Description,  with  illustrative  examples.  The  mechanical  Genius 
of  Earlswood  Asylum, 


XV.  MORAL  DEFICIENCY  AND  CRIMINAL  AMENTS  -     313-341 

Definition  of  morahty.  Legal  definition  of  moral  deficiency 
or  imbeciUty.  Psychological  basis  of  misconduct.  Moral 
sense  and  its  relation  to  moral  deficiency.  Defective  will. 
Morbid  impulses.  Influence  of  heredity  and  environment 
in  production  of  criminal  propensities.  Relation  of  moral 
to  mental  deficiency.  Characteristics  of  habitual  criminal 
class.     Numerical  incidence. 

Description: 

I.  The  morally  perverse  or  habitual  criminal  type.  2.  The 
facile  type.  3.  The  explosive  type.  Illustrative  cases. 
Other  criminal  aments. 

Criminal  Responsibility  of  Aments  : 

Conditions  of  responsibility:  Defective  knowledge,  defective 
control,  delusions.     Civil  incapacity. 


XVI.   INSANE  AMENTS    -  -  -  -  -  -     342-358 

Sane  and  insane  aments.  Predisposition  to  insanity  in 
aments.  Borderland  of  amentia  and  insanity.  Relative 
importance  of  predisposing  and  exciting  factors.  Clinical 
varieties  of  insanity  in  aments.  Mania.  MelanchoUa. 
Stupor.  Alternating  and  recurrent  insanity.  Delusional 
insanity.  Epileptic  insanity.  General  paralysis.  Dementia. 
Illustrative  cases. 


Table  of  Contents  xv 

CHAPTER  PAGES 

XVII.  MENTAL  TESTS  AND  CASE-TAKING  -  -  -     359-379 

Mental  Tests: 

Their  use  and  general  value.  Tests  of  vision.  Hearing, 
taste,  smell,  cutaneous  sensibility,  attention,  associa- 
tion, memory,  description  and  report,  suggestibility, 
emotion,  judgment  and  reasoning,  general  intelligence 
and  capacity,  movement.  De  Sanctis'  tests.  Binet- 
Simon  tests. 

Case-Taking  : 

Previous  personal  history.  Family  history.  Present  con- 
dition. 

XVIII.  DIAGNOSIS  AND  PROGNOSIS  -  -  -  -     380-399 

Diagnosis  : 

During  infancy.  During  childhood  and  school  age.  During 
adolescence  and  adult  life. 

Prognosis: 

Of  the  forms,  varieties  and  degrees. 

XIX.  TREATMENT  AND  TRAINING-  -  -  -     400-423 

Medical  and  Surgical  Treatment. 

Education  : 

The  general  principles  of  education.  Home  training. 
School  training.  The  senses,  movement,  intelligence, 
speech  and  scholastic.  Industrial  training.  Moral 
training. 

XX.  THE  LAW  OF  ENGLAND  CONCERNING  AMENTIA  -     424-431 
Summary  of  the  Mental  Deficiency  Act,  1913. 

XXI.  SOCIOLOGY  -  -  -  -  -  -     432-462 

The  number  of  aments.  Employment.  Pauperism.  Vagrancy. 
Aments  under  inadequate  care.  Crime.  Inebriety.  Propaga- 
tion. Illegitimacy.  Remedial  measures.  Value  of  training. 
Asexuahzation.  Compulsory  segregation.  Regulation  of 
marriage.     Prevention.     Eugenics. 

APPENDIX  .  .  -  -  -  -     463-474 

Nomenclature : 

A  table  of  synonyms. 

A  table  of  normal  developmental  data. 

A  table  of  anomalies  associated  with  amentia. 

A  form  for  case-taking. 

INDEX         -------  475 


LIST  OF  TABLES 

TABLE  PA(.H 

I.  Showing  the  Total  Number  of  Aments,  and  of  Idiots,  Im- 
beciles, AND  Feeble-Minded,  per  1,000  Population,  in 
Certain  Districts  of  the  United  Kingdom  -  -       12 

II.  Showing  the   Relative  Incidence  of  Amentia  in  Certain 

Areas  of  the  United  Kingdom      -  -  -  -       13 

III.  Approximate  Estimation  of  the  Total  Number  of  Aments, 

AND  OF  the  Respective  Degrees,  existing  in  England  and 
Wales  on  January  i,  1906-  -  -  -  -       15 

IV.  Showing  the  Relative  Incidence  of  the  Degrees  of  Amentia 

IN  Certain  Districts  of  the  United  Kingdom     -  -       16 

V.  The  Location  of  All  Aments  in  Eleven  Selected  Areas  of 

England  and  Wales  -  -  -  -  -       18 

VI.  Sex  of  Aments  -  -  -  -  --  -19 

VII.  Classification  of  Amentia      -  -  -  -  -       97 

VIII.  Consonantal  Defects  in  Amentia     -  -  -  -     132 

IX.  Relative  Mortality  of  Aments  and  Non-Aments  -  -     150 

X.  Showing    Age    Periods   of    1,000   Consecutive    Deaths   in 

Earlswood  Asylum  -  -  -  -  -  -151 

XI.  Showing  the  Percentage  of  Deaths  to  the  Number  of 
Patients  in  Residence  at  Earlswood  Asylum  over  a 
Period  of  Twenty-One  Years        -  -  -  -     152 

XII.  Showing  the  Deaths  from  Different  Forms  of  Tuberculosis  153 

XIII.  Showing  the  Cause  of  Death  in  1,000  Consecutive  Deaths 

IN  Earlswood  Asylum  -  -  _  .  -     154 

XIV.  Showing  the  Percentage  of  Mentally  Deficient  Children 

TO  THE  Public  Elementary  School  Population  in  Certain 
Districts  of  the  United  Kingdom  .  .  _     159 

XV.  Showing  the  Relation  of  Epilepsy  to  Amentia    -  -     276 

XVI.  Showing  the  Location  of  Feeble-Minded  Persons  in  Urban 

AND  Rural  Areas  respectively      .  -  -  -     439 

XVII.  The  Number  of  Aments  inadequately  cared  for  -     442 

XVIII.  Showing  the  Condition  of  150  Aments  with  their  Brothers 

and  Sisters    -------     44S 

Appendix — A  Table  of  Synonyms      -  -  -   facing  464 

Normal  Developmental  Data     -  -  -  466 

Anomalies  associated  with  Amentia  -  -  468 

A  Form  for  Case-Taking  _  .  -  471 


LIST  OF   ILLUSTRATIONS 


PLATE  FIGS.  TO  FACE  PAGE 

Frontispiece    1-8.    TYPES   OF   BrAIN    CeLLS    OCCURRING   IN   AMENTIA 

I.  9.  Diagrammatic     Sections     of     Frontal     Cortex    in 

Amentia,  Dementia,  and  the  Normal  Brain        -  74 

II.  10-15.  Mentally  Defective  School-Children          -             -  162 

III.  16.  Mentally  Defective  School-Children  :  The  Little- 

ton House  Scout  Troop      -             -             .             .  jyo 

IV.  17-18.  Primary    Amentia,    Feeble-Mindedness,    Mentally 

Stable  Type  (Males)             -             -             -             -  176 
V.  19-20.  Primary    Amentia,    Feeble-Mindedness,    Mentally 

Unstable  Type  (Females)   -             -             -             -  184 

VI.  21-22.  Primary  Amentia,  Imbecility,  Mentally  Unstable 

Type  (Males)               .             _             .             .             .  igo 

VII.  23-24.  Primary  Amentia,  Imbecility  (Females)       -             -  192 

VIII.  25-26.  Primary  Amentia,  Imbecility  (Males)            -             -  194 

IX.         27.  Primary  Amentia,  Imbecility              .             .             _  jgs 

28.  Primary  Amentia,  Idiocy  with  Sclerosis    -             -  .196 

X.  29-30.  Primary  Amentia,  Idiocy,  Excitable  Type               -  198 

XI.  31-32.  Primary  Amentia,  Microcephalic  Variety  -             -  206 

XII.  33-34.  Primary  Amentia,  Mongolian  Variety         -       •      -  214 

XIII.  35-36.  Primary  Amentia,  Mongolian  Variety,  Children  -  216 

XIV.  37-38.  Primary  Amentia,  Mongolian  Variety,  Children  -  218 
XV.         39.  Secondary  Amentia  due  to  Epilepsy            -             -  236 

40.  Secondary  Amentia  due  to  Cerebral  Lesion         -  236 
XVI.         41.  Secondary   Amentia   with   Paralysis  and  Convul- 
sions DUE  to  Infantile  Lesion       -             -             .  238 
42.  Secondary  Amentia  with  Paraplegia  due  to  Vascu- 
lar Lesion  at  Birth             -             -             -             -  238 
XVII.         43.  Secondary    Amentia    with    Epilepsy    due    to    En- 
cephalitis IN  Infancy            -             -             .             .  240 
44.  Secondary  Amentia  due  to  Encephalitis  in  Infancy  240 

XVIII.         45.  Secondary   Amenita    due   to    Sclerosis   (So-called 

"  Hypertrophy  of  the  Brain  ")     -                          -  254 
xix 


XX 


List  of  Illustrations 


PLATE 

XVIII. 
XIX. 


XX. 

XXI. 
XXII. 


FIGS. 

46. 

47- 


49-50. 
51-52. 

53- 

54- 


XXIII. 

55- 

XXIV. 

56. 

57- 

XXV. 

58. 

59- 

XXVI. 

60. 

61. 

XXVII. 

62-63. 

■CXVIII. 

64-65. 

XXIX. 

66-67. 

Hydrocephalic  and  Microcephalic  Imbeciles 

Secondary  Amentia  due  to  Hydrocephalus,  Child 
i^  Years  Old  -  .  .  .  . 

Female  Microcephalic  Aged  4!  Months   - 

Secondary  Amentia  due  to  Syphilis 

Secondary  Amentia,  Cretinism        .  _  . 

Secondary   Amentia    due   to    Congenital   Blind- 
ness ---... 

Secondary  Amentia  due  to  Deafness  (the  Genius 
OF  Earlswood  Asylum)     -  -  -  . 

Diagrammatic    Life    History    of   the    Genius    of 
Earlswood  Asylum  .... 

A  Crayon  Copy  of  the  Picture  "  Bolton  Abbey  "  - 

A  Fully  Rigged  Man-of-War  ... 

A  Page  of  the  Patient's  Private  Memorandum 
Book  ...... 

The  "  Great  Eastern  "  Steamship  -  .  . 

Criminal  Ament  -  -  -  .  _ 

Insane  Ament  .  _  _  .  . 

Insane  Aments  ..... 

Insane  Aments  .  .  .  .  _ 

Insane  Aments  -  - 


TO  FACE  PAGE 
254 


262 
262 
270 
286 

298 

298 

S08 
310 

312 
312 
346 
346 
348 
350 
352 


MENTAL    DEFICIENCY 

CHAPTER  I 
THE  NATURE  OF  MENTAL  DEFICIENCY 

Literally,  the  term  "  mental  deficiency  "  is  just  as  applicable  to 
a  decay  as  to  a  non-development  of  the  mental  powers,  to  the  dotage 
of  old  age  or  disease  as  to  idiocy  from  birth,  and  it  is  still  often  used 
indiscriminately  of  either  of  these  conditions.  There  is,  however, 
a  great  difference  between  them.  Mental  defect  occurring  subse- 
quently to  mental  development  may  be  compared  to  a  state  of  bank- 
ruptcy, and  is  more  fittingly  described  as  dementia  {de,  down,  from ; 
mens,  mind);  whilst  the  person  whose  mind  has  never  attained 
normal  development  m-ay  be  looked  upon  as  never  having  had  a 
banking  account,  and  this  state  is  designated  amentia  {a,  without; 
mens,  mind).  In  both  of  these,  of  course,  there  is  literally  mental 
•deficiency;  but  in  view  of  the  convenient  and  growing  tendency  to 
xestrict  this  term  to  the  latter  class,  I  shall  in  this  book  use  it  in  a 
specific  sense  as  synonymous  with  "  amentia." 

Mental  deficiency,  or  amentia,  then,  is  that  state  in  which  the 
mind  has  failed  to  attain  normal  development.  But  the  question 
at  once  arises.  What  is  "  normal  "  mental  development  ?  for  there 
is  probably  nothing  in  which  human  beings  differ  more  than  the 
degree  of  their  mental  capacity.  All  civilized  nations  are  composed 
of  men  of  very  varying  grades  of  intellect.  At  the  one  extreme  we 
have  the  genius  of  a  Bacon,  Newton,  Kepler,  Copernicus,  Shake- 
speare, Goethe,  Plato,  or  Galileo.  These  are  succeeded  by  indi- 
viduals of  lesser  but  still  conspicuous  ability,  and  these  again  merge 
into  the  ordinary  average  mass  of  mankind.  Below  this  we  have 
a  section  composed  of  persons  of  inferior  intelligence  whom  we 


2  The  Nature  of  Mental  Deficiency 

may  term  "  dullards."  The  dullards  are  followed  by  the  class 
designated  "feeble-minded";  the  feeble-minded  merge  imper- 
ceptibly into  the  imbeciles,  and  these  again  are  connected  by 
insensible  gradations  with  the  idiots.  The  gross  idiot  is  character- 
ized by  a  complete  negation  of  intellect,  and  thus  stands  at  the 
lowest  extreme  of  mental  development. 

Now,  since  these  variations  of  intellectual  development  appear  to 
form  such  a  continuous  series,  and  since  corresponding  differences 
occur  among  uncivilized  as  well  as  civilized  peoples,  it  might  be 
thought  that  they  were  all  simply  manifestations  of  that  tendency 
to  vary  which  is  the  rule  in  every  form  of  life.  That,  in  fact,  they 
were  all  oscillations  within  the  normal  range  of  development,  and 
that  gross  idiocy  was  just  as  much  an  expression  of  normal  variation 
at  one  end  of  the  scale  as  was  genius  at  the  other.  Theoretically 
this  view  is  very  plausible,  and  it  must  be  admitted  that  the 
differentiation  of  mild  defect  from  the  lowest  grade  of  non-defect 
may  be  sometimes  difficult  to  make;  nevertheless,  I  believe  that 
close  investigation  will  show  that  a  real  dividing-line  does  exist,  and 
that  this  is  of  such  a  nature  as  to  justify  our  regarding  mental 
deficiency  as  no  form  of  normal  variation,  but  as  a  distinctly 
abnormal  and  pathological  condition. 

What  is  this  dividing-line  ?  What  is  the  difference  between  the 
mind  which  we  may  regard  as  normal  and  that  which  we  may  rightly 
consider  to  be  abnormal  and  defective  ?  It  is  obvious  that  the 
question  is  one  of  considerable  scientific  and  social  importance; 
nevertheless,  it  is  one  upon  which  authorities  are  by  no  means 
agreed.  As  is  well  known,  mind  is  the  sum  total  of  many  complex 
functions  and  faculties,  and  the  ideal  mind  would  be  the  one  in 
which  all  these  were  developed  in  due  and  harmonious  proportions. 
But  such  a  mind  has  no  real  existence;  at  any  rate,  no  one  would 
admit  that  the  mind  of  anyone  but  himself  came  up  to  this  standard, 
and  it  is  obvious  that  were  the  "  ideal  "  to  be  taken  as  the  criterion 
of  normality,  all  the  universe  would  be  defective.  Another  standard 
which  has  attracted  considerable  attention  in  recent  years  is  the 
pedagogic  one,  and  it  is  now  often  contended  that  the  criterion  of 
mental  defect  is  inability  to  reach  a  certain  degree  of  scholastic 
proficiency.  But  I  find  it  impossible  to  subscribe  to  this  dictum. 
Undoubtedly  inability  to  progress  in  school  is  a  very  common 
characteristic  of  aments,  but  by  no  means  invariably  so,  and  there 
are  persons  whom  every  mental  specialist  would  agree  in  classing 


The  Nature  of  Mental  Deficiency  3 

as  defective  who  yet  possess  very  considerable  scholastic  attain- 
ments, which  may  be  greater,  indeed,  than  some  members  of  the 
non-defective  class.  On  the  other  hand,  there  are  many  individuals 
who  have  been  complete  failures  at  school,  who  can  yet  look  after 
their  interests,  earn  their  living,  and  discharge  their  duties  in  one  of 
the  humbler  walks  of  life  with  complete  success.  Whilst,  therefore, 
admitting  the  value  of  scholastic  tests  as  an  adjunct  to  diagnosis, 
I  cannot  agree  that  they  form  a  criterion  by  which  the  normal  may 
be  differentiated  from  the  abnormal  mind.  Wherein,  then,  does 
this  difference  lie  ? 

In  seeking  for  a  division  which  shall  be  natural,  scientific,  and 
of  practical  social  utility,  it  seems  to  me  essential  that  we  should 
as  far  as  possible  distinguish  between  those  aptitudes  which  are 
fundamental  and  those  which  are  not  so.  The  innate  develop- 
mental potentiality  of  mind  causes  many  individuals  to  acquire 
aptitudes  which  may  not  only  be  a  source  of  pleasure  and  advantage 
to  themselves,  but  which  may  conduce  very  materially  to  the  benefit 
and  progress  of  the  community  in  general.  The  creations  of  the 
artist,  musician,  and  poet,  the  inventions  of  the  scientist,  even  the 
theological  doctrines  of  the  devout,  are  instances  in  point.  But 
although  innate  capacity  of  this  kind  is  necessary  for  the  advance 
of  the  race,  one  would  not  be  justified  in  considering  those  in  whom 
it  was  lacking  as  mentally  deficient,  for  it  can  hardly  be  regarded 
as  a  fundamental  quality  of  the  human  mind.  Conversely,  the 
presence  of  ability  of  this  kind  is  not  in  itself  proof  of  the  non- 
defectiveness  of  the  person  concerned.  If,  however,  we  find  that  a 
class  of  human  beings  exists  who  are  devoid  of  what  we  must  justly 
regard  as  the  essential  qualities  of  mind,  then  we  are  entitled  to  say 
that  to  that  class  the  term  "  mentally  deficient  "  may  rightly  be 
applied.  The  crucial  question  therefore  is.  What  is  the  essential 
purpose  of  mind  ? 

I  think  it  will  be  generally  conceded  that  the  chief  require- 
ment of  all  living  beings  is  the  power  of  maintaining  existence. 
Other  attributes  may  be  advantageous  and  desirable,  indeed  neces- 
sary, to  a  progressive  evolution;  but  this  one  is  fundamental.  In 
the  lower  forms  of  life  Nature  provides  a  variety  of  means  whereby 
the  individual  is  enabled  to  secure  food,  to  escape  its  enemies,  and 
to  conform  to  its  environment — and  thus  to  survive.  The  uncon- 
scious mimicry  of  many  insects,  the  powerful  weapons  of  offence 
possessed  by  many  of  the  carnivora,  such  defensive  appliances  as 


4  The  Nature  of  Mental  Deficiency 

stings,  spines,  a  horny  integument,  the  emission  of  disagreeable 
odours,  the  possession  of  hmbs  adapted  for  speed,  together  with 
the  highly  developed  instincts  which  are  present  in  so  many  of  the 
lower  forms  of  creation,  are  well  known,  and  reveal  the  devices  of 
Nature  to  attain  this  essential  object  of  life. 

With  the  appearance  of  man,  however,  a  new  phase  is  entered 
upon.  The  alterations  of  anatomical  form,  physiological  function, 
and  general  mode  of  life  have  combined  to  rob  him  of  most  of  the 
means  of  survival  possessed  by  the  lower  orders  of  creation,  and 
have  resulted  in  his  being  no  longer  able  to  hold  his  own  without 
something  to  take  their  place.  Deprived  of  natural  weapons  of 
offence,  he  can  only  secure  food  through  cunning  and  inventiveness. 
Having  no  natural  weapons  of  defence,  he  must  have  recourse  to 
skill  and  strategy  if  he  would  escape  his  enerriies.  Driven  by  force 
of  numbers  to  distant  climates,  intelligence  and  reason  must  guide 
him  in  storing  food  and  devising  bodily  covering  if  he  is  to  evade 
starvation  and  death  from  exposure.  It  may  be,  indeed  it  is  likely, 
that  the  bodily  alterations  and  changes  in  mode  of  life  to  which  I 
have  alluded  are  not  the  cause,  but  the  consequence,  of  man's 
mental  evolution.  The  result,  however,  is  the  same,  in  that  with 
man  the  maintenance  of  existence  has  ceased  to  be  a  matter  of 
brute  force,  unconscious  adaptation,  and  instinct,  and  has  become 
a  conscious  process;  it  is  in  fact  the  essential  concern  of  mind.  I 
regard  this  capacity,  therefore,  as  the  fundamental  quality  of  the 
human  mind.  Other  attributes  may  be  of  advantage  in  furthering 
individual  progress,  but  this  one  is  essential;  the  individual  who 
possesses  it  must  be  regarded  as  "  normal,"  whilst  the  one  in  whom 
it  is  lacking  falls  so  far  short  of  the  minimum  developmental  stage 
of  the  hiunan  species  that  he  must  be  regarded  as  abnormal  and 
mentally  deficient. 

It  may  be  urged,  however,  that  this  criterion  is  fallacious,  inas- 
much as  the  maintenance  of  existence  is  not  dependent  upon  mental 
faculty  alone,  but  upon  the  nature  of  the  environment.  For  instance, 
very  little  capacity  might  be  needed  to  ensure  survival  in  an  equable 
climate,  devoid  of  foes,  and  with  an  abundant  supph'  of  food  to 
hand;  whilst  the  greatest  intelligence  might  not  suffice  to  preserve 
the  life  of  an  individual  cast  alone  upon  a  barren  island.  Again,  in 
a  civilized  society  the  environment  differs  enormously  with  different 
individuals;  and  whilst  the  lot  of  some  (even  defective)  persons  may 
be  so  favourable  as  to  render  their  survival  a  matter  of  the  greatest 


The  Nature  of  Mental   Deficiency  5 

ease,  individuals  not  essentially  lacking  in  this  capacity  may  fail 
to  maintain  existence  owing  to  economic  pressure  or  other  adverse 
social  influences.  Lastly,  since  the  conditions  of  life  vary  greatly 
with  different  phases  of  man's  social  evolution,  it  may  be  said  that 
the  capacity  necessary  for  survival  can  never  be  a  fixed  amount, 
but  must  undergo  a  corresponding  change,  with  the  result  that  an 
individual  who  would  be  classed  as  abnormal  and  defective  amid  a 
civilized  population  might  be  regarded  as  non-defective  among  a 
community  of  savages,  and  that  persons  who  to-day  are  regarded 
as  normal,  might,  in  a  more  advanced  stage  of  social  evolution,  be 
classed  as  defective. 

These  arguments  deserve  attention,  but  I  think  a  little  considera- 
tion will  show  that  they  are  not  really  valid  objections  to  the  con- 
ception of  mental  defect  which  I  have  endeavoured  to  formulate. 
In  the  first  place,  it  is  obvious  that  ability  to  maintain  existence 
must  be  judged  in  reference  to  circumstances  which  normally  obtain, 
not  to  an  environment  which  is  grossly  exceptional.  It  is  perfectly 
true  that  a  state  of  affairs  might  be  imagined  in  which  survival 
needed  no  capacity  beyond  that  possessed  by  some  high-grade 
aments;  indeed,  such  a  state  actually  exists  in  the  case  of  many 
defectives  who  are  so  placed  that  they  do  not  have  to  compete 
for  a  Uving  with  their  fellow-creatures.  But  such  conditions  are  far 
removed  from  the  competition  and  struggle  for  existence  which  is 
the  normal  lot  of  mankind,  and  there  can  be  no  doubt  that  under 
these  latter  circumstances  failure  would  be  the  inevitable  result. 
Again,  with  regard  to  economic  pressure,  it  is  unfortunately  true 
that  the  state  of  the  labour  market  may,  and  frequently  does,  result 
in  a  section  of  the  community  finding  it  impossible  to  make  both 
ends  meet  without  occasional  assistance  from  external  sources. 
But  the  criterion  of  deficiency  is  that  it  is  due  to  inherent,  not  to 
external  or  social,  defects;  that  it  is  psychological,  not  economic; 
and  there  is  not  as  a  rule  much  difficulty  in  distinguishing  between 
the  two.  With  regard  to  the  nature  of  the  demands  made  upon  the 
resources  of  the  individual  by  alterations  in  the  organization  and 
development  of  society,  there  can  be  no  doubt  that  a  great 
change  has  taken  place;  but  it  by  no  means  follows  that  because 
the  adaptation  required  is  different  in  kind,  it  therefore  necessi- 
tates any  higher  mental  capacity.  Indeed,  on  the  whole  it 
seems  likely  that,  in  consequence  of  the  more  specialized  and 
stereotyped  mode  of  life,    survival  becomes  progressively  easier 


6  The  Nature  of  Mental  Deficiency 

as  the  race  advances  from  a  primitive  condition  towards  one  of 
civilization. 

As  will  be  seen  in  discussing  the  psychology  of  the  defective  mind, 
the  precise  nature  of  the  mental  defect  is  subject  to  considerable 
variation  in  different  individuals.  In  every  case,  however — and 
this  is  the  point  I  here  desire  to  emphasize — it  is  such  as  to  render 
the  person  incapable  of  adapting  his  conduct  and  mode  of  life  to 
any  environment  which  is  not  of  an  absolutely  simple  and  stereo- 
typed character.  The  character  of  the  environment  must,  of 
course,  have  some  bearing  on  the  matter,  and  when  that  age  comes 
in  which  social  reform  shall  have  succeeded  in  completely  neutral- 
izing the  force  of  natural  selection,  in  abolishing  the  advantages 
which  now  result  from  initiative,  industry,  and  intelligence  beyond 
the  average,  and  in  reducing  life  to  a  form  of  existence  in  which 
the  doings  of  every  hour  from  birth  to  the  grave  are  carefully 
prescribed  and  supervised  by  an  omniscient  Government,  then  the 
mentally  defective  person  will  be  quite  capable  of  competing  on 
equal  terms  with  any  member  of  the  community.  In  the  absence 
of  such  a  stereotyped  existence,  however,  and  so  long  as  survival 
demands,  not  merely  ability  to  labour,  but  the  prudent  regulation 
of  conduct  in  accordance  with  surroundings  which  vary  from  day 
to  day,  the  mentally  deficient  will  be  incapable  of  so  competing, 
for  in  the. capacity  for  such  adaptation  to  changing  surroundings 
he  is  inherently  defective.  As  things  now  are,  and  as  they  have 
been  since  the  days  of  primeval  man,  human  environment  has  been 
of  this  latter  kind,  survival  has  necessitated  the  presence  of  a 
■capacity  for  adaptation,  and  I  think  we  are  therefore  justified  in 
looking  upon  this  as  the  fundamental  quality  of  mind.  Where  it 
is  present  I  regard  the  individual  as  of  "  normal  "  mental  develop- 
ment, albeit  his  range  of  intelligence  and  degree  of  accomplish- 
ments may  vary  within  very  wide  limits,  thus  constituting  variation 
within  the  normal.  Where  is  it  absent,  I  regard  the  individual  as 
abnormal  and  mentally  deficient,  whatever  other  accomplishments 
he  may  possess.  In  a  former  edition  of  this  book  I  adopted  as  the 
criterion  of  defect  the  inability  of  the  individual  to  perform  his 
duties  as  a  member  of  society  in  the  position  of  life  to  which  he 
was  born,  but  further  consideration  has  caused  me  to  think  that 
this  is  too  narrow,  that  it  does  not  allow  for  those  frequent  slight 
variations  within  the  family  (deteriorations,  if  we  like  to  call  them 
so)  which  are  within  the  normal  compass  of  oscillation ;  accordingly, 


The  Nature  of  Mental  Deficiency  7 

I  now  suggest  as  the  standard  that  of  abihty  to  maintain  existence, 
without  external  support. 

Now,  the  normal  child  comes  into  the  world  in  a  very  immature 
condition.  He  is  quite  incapable  of  independent  survival,  and  it 
is  only  after  many  years  of  training,  after  reiterated  precept  and 
example,  only  too  often  after  painful  and  bitter  experience  of  the 
consequences  attending  mistakes,  that  he  gradually  learns  so  to 
adapt  his  conduct  to  his  environment  as  to  be  capable  of  stand- 
ing alone.  Superficially  considered,  there  would  appear  to  be  a 
considerable  resemblance  between  the  various  stages  of  normal 
evolution  and  the  different  grades  of  mental  defect,  and  hence  it  is 
not  perhaps  surprising  to  find  that  the  degrees  of  amentia  have 
been  regarded  as  simply  due  to  normal  development  being  arrested 
at  corresponding  periods  of  growth.  The  new-born  normal  child 
has  even  been  spoken  of  as  an  idiot.  I  think  this  view  is  most 
fallacious.  In  spite  of  his  immaturity,  the  normal  child  possesses 
a  potentiality  for  development  which  is  far  removed  from  that 
possessed  by  the  abnormal,  and  this  suffices  to  place  the  incapacity 
of  the  latter  on  a  totally  different  plane  to  the  stage  of  incapacity 
through  which  every  healthy  person  passes  in  the  course  of  his 
development.  It  is  perfectly  true  that  in  aments,  as  in  the  non- 
defective,  training  is  essential  to  bring  out  their  potentiality.  The 
inherently  defective  child  who  does  not  receive  this  training  may 
remain  so  undeveloped  as  to  rank  little  higher  than  an  idiot,  whilst 
a  similar  child,  under  suitable  training,  may  have  his  faculties  so 
developed  as  to  be  merely  feeble-minded.  Admitting  this,  how- 
ever, it  must  be  quite  clearly  stated  that  the  difference  between 
the  normal  and  abnormal  Hes  not  in  the  training  they  have  received, 
but  in  their  innate  capacity  to  respond  to  this  training.  The 
mentally  deficient  person  is  one  in  whom  this  innate  potentiality 
is  so  limited  that  no  education  and  no  training  can  avail  to  render 
him  capable  of  the  adaptation  necessary  for  independent  survival. 
It  is  therefore  necessary  to  bear  in  mind  that,  although  it  may  be 
convenient  to  compare  the  various  grades  of  mental  defect  with 
various  stages  of  normal  mental  growth,  this  restricted  potentiahty 
for  development  in  the  ament  constitutes  a  most  important  differ- 
ence; whilst,  in  view  of  this,  the  appHcation  of  the  term  "  idiot  " 
to  the  new-born  normal  child  can  only  be  regarded  as  a  gross  abuse 
of  language. 

It  is  sometimes  stated  that  the  essential  basis  of  amentia  hes  in 


8  The  Nature  of  Mental  Deficiency 

the  non-evolution  of  certain  mental  characteristics  which  are  neces- 
sary to  secure  adaptation  under  modern  conditions — that,  in  short, 
whilst  the  generality  of  mankind  have  advanced  in  mental  capacity, 
aments  represent  an  atavism,  or  harking  back,  to  a  more  primitive 
human  condition.  Apart  from  the  fact  that  amentia  is  not  con- 
fined to  civilized  man,  but  occurs  among  primitive  races,  and  prob- 
ably even  amongst  the  lower  animals,  I  find  it  exceedingly  difficult 
to  believe  that  the  mentally  deficient  members  of  a  civilized  com- 
munity would  be  any  better  able  to  hold  their  own  amid  a  com- 
munity of  savages  than  they  are  in  their  present  environment,  and 
I  find  it  still  more  difficult  to  imagine  that  such  persons  represent 
a  developmental  phrase  in  the  evolution  of  the  human  race.  In 
short,  when  we  come  to  study  the  defective  mind,  we  find  that  not 
only  is  it  characterized  by  a  lack  of  power  for  acquiring  the  funda- 
mental aptitude  for  which  mind  exists,  but  that  such  growth  as  is 
present  is  extremely  likely  to  be  irregular  and  distorted.  The 
lower  members  of  the  normal,  as  represented  by  the  dullards,  may 
be  unable  to  make  any  social  advance.  They  are  heavy,  stolid, 
and  dull-witted;  but  they  yet  possess  sufficient  power  of  adapta- 
tion to  look  after  their  interests  and  to  hold  their  own  imaided. 
The  mild  aments,  on  the  other  hand,  may  show  no  apparent  dullness, 
they  may  even  be  bright  and  vivacious,  and  in  some  of  their  accom- 
plishments immeasurably  superior  to  the  dullard,  but  the  other 
faculties  of  their  minds  are  not  present  in  like  proportions.  Instead 
of  harmonious  working,  there  is  mental  discord,  and  in  the  posses- 
sion of  the  power  so  to  adapt  their  conduct  to  their  environment  as 
to  maintain  an  independent  existence  they  are  fundamentally  lack- 
ing, and  the  want  can  never  be  supplied.  It  is  the  recognition  of 
this  irreducible  minimum  which  enables  us  to  draw  the  line  between 
the  normal  and  the  abnormal,  between  the  physiological  and  patho- 
logical, and  which  justifies  us  in  designating  persons  who  fall  short 
of  it  as  suffering  from  deficiency  of  mind.  The  condition  is  a 
psychological  one,  although  the  criterion  is  a  social  one,  and  we 
may  accordingly  define  amentia  as  a  state  of  restricted  potentiality 
for,  or  arrest  of,  cerebral  development,  in  consequence  of  which  the 
person  affected  is  incapable  at  maturity  of  so  adapting  himself  to  his 
environment  or  to  the  requirements  of  the  community  as  to  maintain 
existence  independently  of  external  support. 

The  two  other  chief  forms  of  mental  disease  are  dementia  and 
insanity.     The  former  of  these  has  already  been  referred  to,  and 


The  Nature  of  Mental  Defic 


lency 


is  the  result  of  neuronic  degeneration;  whilst  "insanity"  is  the 
clinical  manifestation  of  a  disturbance  or  perversion  of  neuronic 
function,  which  may  or  may  not  terminate  in  degeneration,  and 
which,  as  we  shall  subsequently  see,  is  by  no  means  incompatible 
with  neuronic  deficiency  or  amentia. 

***** 
I  think  it  will  be  evident  that  the  condition  of  amentia,  whilst 
presenting  many  interesting  problems  to  the  physician,  the  path- 
ologist, and  the  psychologist,  has  also  a  much  wider  interest  and 
importance.  Since  in  Man  the  predominant  feature  is  Mind,  and 
since  it  is  by  the  development  of  this  faculty  that  human  progress 
has  taken,  and  must  take,  place,  it  is  clear  that  the  question  of  its 
disease,  and  particularly  of  its  defect,  is  one  of  supreme  importance 
to  the  statesman,  the  sociologist,  and  the  philosopher. 


CHAPTER   II 

INCIDENCE 

The  enumeration  of  the  mentally  deficient  population  of  any 
country  is  an  extremely  difficult  matter,  and  there  can  be  no  doubt 
that  most  official  inquiries,  particularly  those  by  means  of  the 
ordinary  census,  fall  very  far  short  of  the  truth.  The  reasons  for 
this  are  numerous,  the  chief  being  the  inability  or  unwillingness  of 
parents  to  recognize  mental  abnormality,  their  total  incapacity  to 
distinguish  between  its  various  forms,  and  their  not  unnatural 
reluctance  to  proclaim  its  presence  on  a  census  paper.  The  milder 
forms  of  defect,  which  are  at  once  the  most  frequent  and  the  most 
important  from  a  sociological  aspect,  cannot  possibly  be  detected 
by  such  means.  For  these  reasons  I  am  of  opinion  that  the  official 
returns  of  any  country  respecting  the  number  of  its  aments  are  so 
unreliable  and  incomplete  that  no  useful  purpose  would  be  served 
by  quoting  them. 

Investigations  of  the  English  Royal  Commission  of  1904. 

In  this  country,  however,  an  enumeration  has  recently  been 
made  on  quite  another  basis.  In  the  year  1904  a  Ro3"al  Commis- 
sion was  appointed  to  consider  the  existing  methods  of  dealing  with 
these  persons,  and  the  Commissioners  decided  that,  before  any 
practical  scheme  of  administration  could  be  formulated,  it  was 
imperative  that  they  should  obtain  approximately  accurate  infor- 
mation as  to  the  number  and  condition  of  the  class.  The  Com- 
missioners remark:  "  Almost  at  the  outset  of  our  inquiry  we  found 
that  there  were  no  available  statistics  from  which  any  trustworthy 
estimate  could  be  made  as  to  the  nimiber  of  persons  who  might  be 
said  to  fall  within  one  or  other  of  the  categories  named  in  our  refer- 
ence. We  decided,  therefore,  than  an  expert  investigation  of  the 
matter  was  indispensable."     With  this  object,  a  series  of  personal 


English  Royal  Commission  of  1904  ir 

investigations  were  instituted  on  a  considerable  scale,  and  this  is 
the  first  systematic  attempt  which  has  been  made  to  obtain  reliable 
data.  It  is  not  too  much  to  say  that  these  inquiries  have  added 
■enormously  to  our  knowledge  regarding  the  condition,  manner  of 
living,  and  environment  of  the  aments  of  this  countr}/,  besides 
making  it  possible  to  calculate  their  total  number  with  a  degree  of 
accuracy  hitherto  unattainable. 

The  method  adopted  by  the  Royal  Commission  consisted  of  a 
series  of  elaborate  and  searching  inquiries  by  a  number  of  medical 
men,  to  each  of  whom  a  selected  area  was  assigned.  The  investi- 
;gator  was  instructed  to  visit  personally  all  public  elementary 
schools,  poor-law  institutions,  charitable  establishments,  training- 
homes,  reformatories,  common  lodging-houses,  prisons,  idiot 
asylums,  hospitals,  and,  indeed,  any  establishment  likely  to  harbour 
the  mentally  abnormal.  Further,  he  was  to  see  persons  in  receipt 
of  outdoor  relief,  to  apply  to  the  clergy,  medical  practitioners, 
the  police,  charity  organization  societies,  and  similar  agencies,  and, 
in  short,  to  make  use  of  any  and  every  channel  which  might  help 
him  to  make  the  enumeration  complete. 

It  was  not  found  practicable  to  investigate  the  whole  of  the 
country  in  this  way,  but  in  order  that  conclusions  applicable  to  the 
-entire  country  might  be  drawn,  a  selection  of  certain  typical  areas 
•was  made.  Altogether,  there  were  examined  nine  areas  in  England, 
two  in  Wales,  one  in  Scotland,  and  four  in  Ireland,  having  an 
aggregate  population  of  3,873,151. 

It  is  extremely  gratifying  to  be  able  to  state  that  the  majority 
■of  the  recommendations  of  the  Royal  Commission  have  now  re- 
■ceived  the  sanction  of  Parliament,  and  although  the  Mental  De- 
ficiency Act  of  1913  cannot  be  regarded  as  a  final  settlement  of  the 
question,  it  is  certainly  a  measure  which  cannot  fail  to  operate  to 
the  advantage  of  the  defectives  themselves  and  of  the  whole  com- 
munity. 

I  shall  again  allude  to  many  facts  revealed  by  this  inquiry  in 
subsequent  chapters;  but  in  this  place  some  statistics  regarding 
the  ascertained  number  of  aments  may  be  quoted. 

The  total  number  of  aments  varies  in  the  different  areas  exam- 
ined, and  although  to  a  slight  extent  this  may  be  due  to  different 
personal  equations,  in  many  cases  the  difference  is  so  great  that  it 
can  only  be  regarded  as  the  result  of  a  real  difference  of  incidence. 
This  is  shown  in  the  following  table : 


12 


Incidence 


TABLE  I.* 

Showing  the  Total  Number  of  Aments,  and  of  Idiots,  Imbeciles,  and 
Feeble-minded  respectively,  per  i,ooo  Population,  in  Certain 
Districts  of  the  United  Kingdom,  according  to  the  Investigations 
OF  the  Royal  Commission,  1904. 


Feeble-minded. 

Idiots. 

Imbe- 
ciles. 

Total 
Aments. 

Adults. 

Children. 

i 

r  Manchester    . . 

0-05 

0-32 

I'20 

2TO 

S-T"* 

Birmingham  .  . 

0-09 

0-27 

I-70 

I -60 

3-76 

„  ,                    Hull     .  . 
Urban       ..-'|  Glasgow 

0-02 

0'20 

0-55 

0-58 

1-35 

coy 

0-23 

0-32 

I -00 

1-68 

Dubhn 

0'i9 

0-57 

I'20 

2-IO 

4-14 

1,  Belfast 

0-13 

0-63 

0-70 

0-97 

2-45 

j'  Stoke-on-Trent 

0'2I 

0-45 

2-IO 

I-IO 

3-96 

Industrial .  .  -  Durham 

0-02 

0-34 

0-56 

0*56 

1-48 

[Cork    .. 

0-07 

0-32 

0'i6 

0-54 

1-10 

Mixed        /"Nottingham- 
Industrial          shire 

0.30 

0-66 

I-50 

I-20 

3-81 

and         1  Carmarthen- 
Agricultural  I     shire 

0-59 

0-65 

0-51 

I'20 

3-05 

r  Somersetshire 

o-i8 

I  "00 

2'IO 

I-IO 

4-54 

Wiltshire 

0-35 

0-69 

2'20 

0-90 

4-25 

Agricultural  Lincolnshire  .  . 

0-44 

0-98 

1-40 

1-70 

4-68 

Carnarvonshire 

0-24 

0-58 

2-IO 

0-94 

3-96 

VGalway 

0-13 

I -00 

I -00 

2'20 

4-49 

It  will  be  seen  from  this  table  that,  whilst  the  mean  average- 
incidence  of  amentia  in  the  sixteen  areas  is  3-28  per  1,000  popu- 
lation, the  variation  ranges  from  a  minimum  of  i-i,  in  the  case  of 
Cork,  to  a  maximum  of  4-68  in  the  case  of  Lincolnshire.  The  fol- 
lowing table  shows  the  areas  grouped  according  to  the  prevalence 
of  amentia: 

*  The  figures  in  this  table  slightly  underestimate  the  true  incidence  for 
the  reason  that  they  do  not  include  a  small  proportion  of  cases  certified  under 
the  Lunacy  Act. 


Number  of  Aments  in  England   and  Wales 


13 


TABLE  11. 

Showing  the  Relative  Incidence  of  Amentia  in  Certain  Areas 
OF  THE  United  Kingdom. 


Low  Incidence 

Mean  Average  Incidence 

High  Incidence 

{under  3  per  1,000 

(3  to  4  per  1,000 

[over  4  per  1,000 

Population) . 

Population). 

Population) . 

Hull 

Manchester 

Dublin 

Glasgow 

Birmingham 

Somersetshire 

Belfast 

Stoke-on-Trent 

Wiltshire 

Durham 

Nottinghamshire 

Lincolnshire 

Cork 

Carmarthenshire 
Carnarvonshire 

Galway 

It  is  thus  seen  that  the  incidence  of  amentia  in  this  country  is 
far  from  being  uniform ;  that,  in  fact,  great  differences  exist  between 
areas  in  which  there  is  httle  difference  in  physical,  social,  and 
industrial  features.  By  means  of  the  annual  reports  of  the  Lunacy 
Commissioners  I  have  ascertained  that  the  same  applies  to  the  inci- 
dence of  insanity,  and  that,  on  the  whole,  there  is  a  tolerably  close 
correspondence  between  the  relative  extent  of  the  two  conditions 
(amentia  and  insanity).  The  cause  of  this  differing  prevalence  of 
mental  disease  is  not  clear,  and  its  investigation  would  probably 
necessitate  very  minute  inquiries  into  the  social,  industrial,  and 
hereditary  condition  of  the  people  over  a  long  period.  Since,  how- 
ever, it  relates  rather  to  mental  disease  in  general  than  to  amentia 
in  particular,  it  is  beyond  the  scope  of  this  work  to  do  more  than 
allude  to  it. 


The  Number  of  Aments  in  England  and  Wales. 

If  the  incidence  of  amentia  were  tolerably  uniform  throughout 
the  country,  it  would  be  a  very  simple  matter  to  calculate  the  total 
number  of  affected  persons  from  the  figures  revealed  by  this  inquiry  ; 
but,  as  we  have  seen,  the  incidence  is  very  far  from  being  uniform. 
It  would  also  be  quite  easy  could  it  be  shown  that  the  proportion 
of  low  to  high  prevalent  areas  in  those  examined  were  relatively  the 
same  as  obtains  in  the  whole  country — if,  in  fact,  we  could  be  certain 


14  Incidence 

that  we  were  dealing  with  a  fair  sample — but  there  is  no  a  priori 
evidence  that  this  is  so.  Consequently  the  estimation  is  a  some- 
what complicated  one.  I  believe,  however,  that  by  using  the 
incidence  of  insanity  as  a  standard  we  may  arrive  at  a  result  which 
is  approximately  correct.  All  insane  persons  are  not,  of  course, 
certified,  but  the  returns  of  the  Lunacy  Commissioners  regarding 
the  number  of  the  certified  pauper  insane  may  be  accepted  as  a 
sufficiently  accurate  indication  of  the  relative  prevalence  of  insanity 
in  the  various  union  districts  of  England  and  Wales.  The  incidence 
of  amentia,  as  already  remarked,  is,  on  the  whole,  directly  pro- 
portionate to  the  incidence  of  insanity.  Now,  if  we  calculate  the 
proportion  per  i,ooo  population  of  the  certified  pauper  insane  in  the 
eleven  areas  of  England  and  Wales  investigated  by  the  Royal  Com- 
mission of  1904,  it  works  out  at  3-15;  but  if  we  calculate  the  pro- 
portion per  1,000  of  the  certified  pauper  insane  throughout  the 
country  (using  in  each  case  the  returns  of  the  Lunacy  Commission* 
and  the  population  according  to  the  1901  censusf),  it  works  out  at 
3-42.  So  that  the  mean  average  incidence  of  insanity,  and  conse- 
quently of  amentia,  in  these  areas  is  less  than  the  mean  average  for 
the  entire  country,  and  this  can  onty  be  due  to  the  fact  that  the 
eleven  areas  examined  contain  a  greater  relative  proportion  of 
districts  of  low  incidence. 

The  actual  number  of  aments  in  the  country  is  therefore  expressed 
by  the  equation : 

Aments  :  certified  insane  :  :  aments  :  certified  insane 


in  areas  examined  in  England  and  Wales 

From  which  it  follows  that  the  total  number  of  aments  in  England 
and  Wales  on  January  i,  1906,  was  approximately  138,529  persons, 
equivalent  to  (with  an  estimated  population  on  that  date  of 
34,349,435,  according  to  the  Registrar-General)  4-03  persons  per 
1,000,  or  I  in  every  248. 

*  Total  pauper  certified  insane  in  England  and  Wales  on  January  i,  1906, 
according  to  the  Sixtieth  Report  of  Lunacj'  Commissioners  =  111,256.  Total 
pauper  insane  in  the  areas  investigated,  as  obtained  from  Table  I.,  Appendix  B, 
of  same  report  =  7,328. 

f  Population  of  England  and  Wales,  according  to  1901  census  =  32,525,716. 
Population  of  the  eleven  areas  examined,  according  to  1901  census  =  2,321,567. 


Incidence  of  the  Three  Degrees  of  Amentia      15 


The  Number  of  Persons  suffering  from  Each  of  the  Three  Degrees 
of  Amentia  in  England  and  Wales. 

This  also  may  be  calculated  from  the  statistics  of  the  Royal  Com- 
mission, and  the  results  arrived  at  are  shown  in  the  following  table : 

TABLE  III. 

Approximate  Estimation  of  the  Total  Number  of  Aments,  and  of 
THE  Respective  Degrees,  existing  in  England  and  Wales  on 
January  i,  1906. 

{Estimated  Total  Population  according  to  Registrar-General,  34,349,435.) 

Idiots  .  .  .  .  .  .      8,654     persons,  or  0*25  per  1,000  population. 

Imbeciles     . .  .  .  . .   25,096  ,,  0-73  ,,  ,, 

Feeble-minded{^^^i*jf^^;;  54-^14*  ..  i;57 


Total    ..  ..     138,529  „  4-03 

(or  I  person  in  every  248) . 


The  Relative  Incidence  of  the  Three  Degrees  of  Amentia. 

It  is  seen  from  Table  III.  that  idiots  are  decidedly  the  least 
numerous  of  the  three  degrees  of  amentia ;  that  imbeciles  occur  next 
in  frequency,  being  nearly  three  times  as  plentiful;  whilst  the 
number  of  the  feeble-minded  is  more  than  three  times  as  great  as  the 
idiots  and  imbeciles  combined.  In  other  words,  taking  the  country 
as  a  whole,  there  are  in  every  100  aments  : 

Idiots.  Imbeciles.  Feeble-minded. 


Adults.  Children. 

39  37 


Or  in  every  10,000  population  there  are  (taking  the  nearest  whole 
numbers) : 

Idiots.  Imbeciles.  Feeble-minded.  Insane. 


Adults.  Children. 

2  7         '  15  14  36 

*  It  seems  probable  that  the  excess  of  adult  over  juvenile  feeble-minded 
is  due  to  the  inclusion  in  the  former  group  of  4,450  patients  in  asylums. 
The  majority  of  these  belong  to  the  mildest  type  of  mental  defect,  and  are 
detained  on  account  of  insanity  or  epilepsy.  If  seen  during  the  school 
period,  they  would  probably  be  looked  upon  as  doubtful,  and  given  the 
benefit  accordingly.  Their  condition  becomes  obvious  when  competition 
with  the  outside  world  has  to  be  faced. 


i6 


Incidence 


There  are,  however,  certain  variations  in  the  relative  incidence 
of  these  degrees  of  amentia  which  seem  to  be  referable  to  the 
environment,  and  to  these  brief  allusion  must  be  made.  It  is  found 
that  the  severer  degrees  of  defect  (idiots  and  imbeciles)  are  both 
relatively  and  absolutely  much  more  numerous  in  agricultural  than 
in  urban  and  industrial  areas,  whilst  in  the  case  of  the  juvenile 
feeble-minded  (mentally  defective  children)  the  results  are  reversed, 
these  being  both  relatively  and  absolutely  more  numerous  in  urban 
than  in  agricultural  areas.  The  actual  figures  will  be  seen  by 
reference  to  Tables  L  and  IV. 


TABLE  IV. 

Showing  the  Relative  Incidence  of  the  Degrees  of  Amentia  in  Certain 
Districts  of  the  United  Kingdom.  Calculated  from  the  Returns 
OF  THE  Royal  Commission,  1904. 


In  Every  100  Aments 

there  are — 

1 

j 

Feeble-minded. 

•rj. 

:  XniD6Cll£S. 

Adults. 

i  Children. 

/'Manchester 

1-5 

- 

8-6 

31-0 

57*o 

Bixmingliain    . . 

2-5 

7-2 

45 -o 

44-0 

Urban..          ..-'^^^ 

1-5 

7.8 

44-0 

46-0 

Glasgow 

4-3 

13-7 

19-4 

62-6 

DubHn 

4-6 

14-0 

30-0 

51-3 

V-Belfast 

5-3 

25-9 

29-0 

39-5 

[  Stoke-on-Trent 

5-3 

II-4 

53'0 

30-0 

Industrial       .  .  -  Durham 

[Cork      

1-5 

23-0 

37-0 

38-0 

6-7 

2g-o 

15-0 

49-0 

""Sfai'frd /^°"-g^--^i^-  •• 

8-1 

I7'0 

4i'0 

32-0 

igncuwt    (Carmarthenshire         .. 

14-0 

22'0 

i8-o 

44-0 

( Somersetshire  . . 

4-0 

23-0 

47-0 

25-0 

Wiltshire 

8-3 

15-0 

52-0 

23-0 

Agricultural  .  .  -  Lincolnshire     . . 

9-5 

21'0 

31-0 

37'0 

Carnarvonshire 

6-0 

I4'0 

55-0 

24-0 

[  Galway 

2-9 

22-8 

23*7 

50-5 

Inasmuch  as  the  inquiries  from  which  these  statistics  are  com- 
piled excluded  all  persons  certified  under  the  Lunacy  Act,  there  is  a 
slight  fallacy  in  these  figures.     In  order  to  ascertain  the  extent  of 


Incidence  of  Amentia  Relative  to  Insanity       17 

this,  I  made  a  special  investigation  as  to  the  total  number  of  aments 
(certified  and  uncertified)  in  a  few  of  the  areas  examined.  The 
results  show  that  the  proportion  excluded  does  not  appreciably  alter 
the  relative  incidence  as  shown  in  Table  IV.  The  cause  of  this 
difference  of  relative  incidence  will  be  discussed  in  a  subsequent 
chapter. 

Incidence  of  Amentia  Relative  to  Insanity. 

It  has  been  stated  that  the  incidence  of  amentia  is  directly 
proportionate  to  that  of  insanity,  and  on  the  whole  this  is  true ;  for 
it  is  found  that  where  insanity  is  rife  amentia  is  also  prevalent,  and, 
conversely,  where  there  is  little  insanity  there  is  little  amentia. 
The  inquiries  of  the  Royal  Commission  show,  however,  that  the 
relative  incidence  of  these  two  forms  of  mental  disease  is  subject 
to  shght  variations  according  to  the  environment,  and,  generally 
speaking,  amentia  would  appear  to  be  relatively  more  prevalent 
in  i"ural,  and  insanity  in  urban,  districts. 

The  aments  are  a  slightly  more  numerous  class  than  the  insane, 
for  a  calculation  of  the  total  number  of  the  latter  (uncertified  as 
well  as  certified)  shows  that  the  approximate  number  of  this  class 
in  England  and  Wales  on  January  i,  1906,  was  125,827,  corre- 
sponding to  3-66  per  1,000  population,  or  to  i  person  in  every  273. 

The  approximate  total  number  of  persons  suffering  from  all  forms 
of  pronounced  mental  disease  (amentia,  insanity,  and  dementia)  in 
England  and  Wales  in  1906,  therefore,  is  264,356,  equivalent  to 
7-69  per  1,000,  or  i  person  in  every  130. 

Location. 

In  order  to  give  a  general  idea  as  to  the  location  of  these  aments 
I  append  the  following  table  (V.,  p.  18),  which  shows  the  situation 
of  the  8,079  persons  revealed  by  the  inquiries  of  the  Royal  Com- 
mission, together  with  those  not  so  included  on  account  of  being 
certified  under  the  Lunacy  Act. 

Incidence  with  Regard  to  Sex. 

The  sex  of  the  12,120  aments  discovered  in  sixteen  areas  of  the 
United  Kingdom  is  as  shown  in  Table  VI. 

It  is  there  seen  that,  considered  either  in  regard  to  each  degree  or 


i8 


Incidence 


collectively,  there  is  a  slight  preponderance  of  the  male  sex,  the 
relative  proportion  of  males  to  females  being  practically  as  6  to  5. 
It  is  probable  that  of  all  aments  bom  a  considerably  greater  pro- 
portion than  this  are  of  the  male  sex ;  but  that  the  number  of  these 
is  subsequently  dismissed  by  a  relatively  higher  infantile  mortality. 
It  is  of  interest  to  note  that  the  ratio  of  males  to  females  is  highest 
of  all  in  the  group  of  feeble-minded  children,  in  which  there  are 
approximately  3  males  to  2  females. 


TABLE  V. 


Showing  the  Location  of  All  Aments  in  Eleven  Selected  Areas  of 
England  and  Wales.  Mainly  based  upon  the  Inquiries  of  the 
Royal  Commission,  1904. 


*   Charitable  institutions  are  composed  as  follows : 

Institutions   for   the   bhnd,   deaf,   crippled,   epileptic,    and   defective,. 

21  persons. 
Training  and  rescue  homes,  penitentiaries,  etc.,  128  persons. 


Incidence   with   Regard    to    Sex 


19 


That  a  greater  number  of  aments  are  to-day  resident  in  institu- 
tions than  was  the  case  a  generation  back  is,  I  think,  incontestable, 
and  the  exigencies  of  modern  Hfe  must  undoubtedly  lead  to  an 
increase  of  this  number  in  years  to  come;  but  as  to  whether  the 

TABLE  VI. 

Showing  the  Sex  of  Aments. 


Idiots. 

Imbe- 
ciles. 

Feeble-minded. 

Totals. 

Adults. 

Children. 

Males . . 
Females 

303 
282 

959 

848 

3.244 
2.193 

2,179 
2,112 

6,685 
5.435 

condition  is  or  is  not  more  prevalent  than  formerly,  or  as  to  the 
relative  incidence  in  different  countries,  we  have  no  data  upon 
which  to  form  an  opinion.  It  is  quite  clear,  however,  from  the 
statistics  here  given,  that  even  on  account  of  its  present  prevalence 
the  condition  is  one  deserving  the  gravest  consideration. 


CHAPTER    III 
CAUSATION 

Amentia  has  been  defined  as  a  state  of  imperfect  or  arrested 
cerebral  development,  and  in  the  investigation  of  its  causes  we 
have  to  inquire  into  all  the  influences  concerned  in  embryonic 
development,  as  well  as  those  affecting  the  growth  of  the  brain 
after  birth.  In  other  words,  we  must  ascertain  as  completely  as 
possible  the  family  and  the  early  personal  history  of  these 
afflicted  persons.  Now,  such  an  inquiry  is  by  no  means  easy;  it 
requires  not  only  a  considerable  amount  of  special  knowledge  in 
order  rightly  to  interpret  the  accounts  furnished  by  unscientific, 
and  often  ignorant,  persons,  but  it  also  demands  much  patience 
and  tact.  The  not  unnatural  reluctance  evinced  by  the  majority 
of  persons  to  admit  the  presence  of  mental  unsoundness  in  the 
family  often  leads  to  the  deliberate  withholding  of  information, 
whilst  a  strongly  prejudiced  view  of  the  importance  of  some  one 
particular  factor  may  cause  all  others  to  be  ignored,  and  so  greatly 
mislead  the  investigator.  I  do  not  think  there  is  any  disease  in 
which,  in  the  minds  of  parents  and  relatives,  the  post  hoc  ergo  propter 
hoc  opinion  figures  more  largely. 

Nevertheless,  a  very  large  number  of  cases  have  now  been  exam- 
ined, and  although  the  opinions  of  inquirers  differ  slightly  as  to 
their  relative  importance,  there  is  a  very  general  agreement  as  to 
the  main  influences  which  are  responsible  for  the  imperfect  con- 
dition of  the  brain  ceUs. 

It  would  be  too  large  a  task  to  refer  to  all  the  work  which  has 
been  done  in  this  direction,  even  in  this  country  alone ;  and  as  I  have 
myself  devoted  much  time  to  the  subject,  and  have  investigated  the 
antecedents  of  a  large  number  of  these  patients,  I  propose  to  give 
my  own  results,  alluding  where  necessary  to  the  points  upon  which 
they  differ  from  those  of  other  inquirers.     My  reason  for  doing  this 


General   Considerations  21 

is  that  the  question  of  causation  not  only  involves  the  ascertain- 
ment of  facts,  but  the  careful  analysis  and  consideration  of  such 
facts  in  conjunction  with  the  clinical  features  of  the  patients,  and  I 
feel  more  competent  to  do  this  with  data  personally  collected  than 
with  those  obtained  by  other  persons.  My  investigations  embrace 
patients  seen  in  the  asylums  of  the  London  County  Council,  the 
special  institutions  at  Darenth  and  Earlswood,  the  Littleton  Home 
for  Defective  Children,  and  my  own  private  practice,  and  they 
include  every  grade  and  variety  of  amentia.  This  point  is  important 
because  the  type  of  case  varies  much  in  different  institutions,  and 
statistics,  however  numerous,  which  are  confined  to  any  one  insti- 
tution, are  apt,  on  that  account,  to  be  misleading. 

General  Considerations. 

In  dealing  with  this  subject  it  has  been  customary  for  writers  to 
divide  cases  of  amentia  into  two  groups — namely,  "  congenital  " 
and  "  acquired  " — according  to  whether  the  condition  was  pres- 
ent at  birth  or  arose  from  the  operation  of  causes  after  birth. 
It  is  clear,  however,  that  from  both  the  scientific  and  practical 
aspects,  the  real  question  is  that  of  the  respective  influences  exerted 
by  heredity  and  environment,  and  regarding  this  the  terms  "  con- 
genital "  and  "  acquired  "  may  give  rise  to  considerable  miscon- 
ception. For  instance,  a  congenital  condition  may  be  caused  by 
a  factor  of  the  environment  acting  during  uterine  existence,  and 
therefore  really  be  acquired;  whilst  it  often  happens  that  mental 
defect  may  not  show  itself  until  several  years  after  birth,  and  thus 
apparently  be  acquired,  although  it  is  actually  due  to  innate  causes. 
For  these  reasons  I  have  thought  it  better  to  discard  these  words 
entirely,  and  to  use  instead  the  terms  intrinsic  and  extrinsic. 

Under  the  former  heading — intrinsic — I  include  any  variation  or 
pathological  condition  of  the  germ  plasm  which  results  in  imperfect 
development  of  the  brain,  and  this  variety  of  amentia  I  term 
intrinsic,  or  primary.  Mental  defect  of  this  kind  is  therefore  a 
result  of  inheritance,  although,  as  will  subsequently  be  seen,  it 
may  not  be  actually  "  hereditary  "  in  the  strict  sense  of  that  word. 
By  extrinsic  causes  I  mean  any  factors  of  the  environment  which 
are  capable  of  prejudicially  affecting  the  brain  development  of  the 
offspring  after  conception  has  taken  place;  in  other  words,  of  pro- 
ducing somatic  modifications.     These   factors  may  be   intra-   or 


22  Causation 

extra-uterine,   and  this  variety  of  amentia  I  term  extrinsic,   or 
secondary. 

I  propose  first  of  all  to  allude  to  some  general  considerations 
regarding  the  etiology  of  amentia.  I  shall  subsequently  give  a 
more  detailed  account  of  the  chief  intrinsic  and  extrinsic  factors 
which  have  been  found  to  be  associated  with  this  condition. 

The  Relative  Influences  of  Inheritance  and  Environment. 

One  of  the  most  important  practical  questions  is  that  of  the 
effects  produced  by  inheritance  and  environment  respectively. 

In  the  investigation  of  individual  cases  the  proportion  in  which 
some  adverse  condition  of  the  environment  is  alleged  as  the  cause 
is  very  considerable ;  and,  bearing  in  mind  that  evidence  of  this  kind 
is  much  easier  to  elicit  than  are  details  of  the  family  history,  it  is 
not  surprising  that  many  former  writers  should  have  attributed 
great  importance  to  such  factors.  At  the  beginning  of  my  inquiries 
I  was  inclined  to  do  so  myself,  and  it  was  only  when  I  found  how 
frequently  morbid  inheritance  lay  behind  that  I  came  to  a  different 
conclusion.  I  am  far  from  denying  that  the  environment,  even  in 
the  presence  of  innate  tendencies  to  defect,  has  no  influence.  What 
I  wish  to  point  out,  however,  is  that  mental  defect  is  but  rarely 
caused  by  injurious  external  factors  acting  alone,  and  that  in  an 
overwhelming  proportion  of  cases  the  cause  lies  in  the  condition  of 
the  germ  plasm. 

This  question  has  such  important  sociological  bearings  that  it  will 
not  be  out  of  place  to  quote  some  of  the  evidence  tendered  to  the 
Royal  Commission  on  the  Feeble-minded  regarding  it.* 

Professor  Sir  T.  Clifford  AUbutt  said :  "  I  regard  feeble-mindedness 
(if  not  accidental)  as  always  hereditary.  ...  I  have  never  met 
with  a  case  of  manufactured  feeble-mindedness  apart  from  some 
accidents  either  at  birth  or  afterwards."  Dr.  Henry  Ashby,  speak- 
ing of  all  grades  of  mental  defect  found  in  early  life,  said:  "In  at 
least  75  per  cent,  of  the  children  with  amentia  that  I  have  examined 
there  was  a  strong  probability  that  the  amentia  was  hereditary  and 
primary."  Dr.  Ashby  further  stated  that  he  had  observed  no 
special  tendency  in  the  children  of  alcoholics,  or  of  women  who 
suffer  privation  during  pregnancy,  or  in  those  children  who  live  in 
unfavourable  conditions  subsequent  to  birth,  to  develop  amentia. 

*  Report  of  the  Royal  Commission  on  the  Feeble-minded,  vol.  viii., 
chap,  xxvii.,  1908. 


General   Considerations  23 

Dr.  Bedford  Pierce  stated  that  he  considered  heredity  to  be  "  by 
far  the  most  important  factor,  and  relatively  more  important  in 
mental  enfeeblement  (amentia)  than  in  insanity."  Dr.  Bevan 
Lewis  said :  "  There  is  not  the  least  doubt  of  it  in  my  mind.  I  look 
upon  feeble-mindedness  as  a  germinal  variation."  Mr.  Frederick 
Wilkinson,  Director  of  Education,  Bolton,  stated  that  in  almost 
every  case  where  parents  of  mentally  defective  children  appeared 
before  the  committee  or  before  magistrates,  it  was  found  that  the 
parents  themselves  were  similarly  afflicted,  and  he  adduced  evidence 
in  support  of  this  statement. 

Similar  evidence,  attested  by  numerous  cases,  was  tendered  to 
the  Royal  Commission  by  Dr.  F.  W.  Mott,  Dr.  Hubert  Bond,  Dr. 
James  Kerr,  Dr.  Fletcher  Beach,  Sir  James  Crichton-Browne, 
Dr.  Beresford,  Dr.  Scott,  Dr.  Parker  Wilson,  Dr.  Sherlock,  Dr. 
Smalley,  myself,  and  several  others;  whilst  Professor  Sir  E.  Ray 
Lankester  and  Dr.  Archdall  Reid,  dealing  with  the  problem  from  the 
biological  aspect,  agreed  that  the  great  majority  of  cases  of  mental 
defect  were  innate  and  transmissible. 

Practically  the  only  evidence  submitted  to  the  contrary  came 
from  Dr.  C.  Mercier,  Dr.  Eichholz,  and  Dr.  R.  Hutchison.  Dr. 
Mercier  admits  the  importance  of  heredity  in  the  production  of  the 
more  severe  grades  of  amentia  (idiocy  and  imbecility) ;  but  con- 
siders that  the  environment  may  play  an  important  part  in  the 
causation  of  the  milder  degree  of  feeble-mindedness.  Dr.  Eichholz's 
evidence  related  to  the  children  attending  special  schools,  but  since 
he  stated  that  from  40  to  50  per  cent,  of  these  children  recovered 
under  care  and  training,  it  is  obvious  that  his  remarks  do  not 
apply  to  the  really  mentally  defective. 

It  is  quite  clear,  therefore,  that  there  is  now  an  overwhelming 
body  of  evidence  from  those  qualified  by  experience  to  express  an 
opinion  on  this  matter,  to  the  effect  that  in  the  great  majority  of 
cases  of  amentia  the  condition  is  due  to  innate  or  germinal  causes, 
and  that  it  is  transmissible.  This  was  the  finding  of  the  Royal 
Commission. 

The  Nature  of  the  Germinal  Defect. 

The  exceedingly  interesting  and  important  question  now  arises. 
What  is  the  nature  of  this  germinal  impairment  ?  In  a  certain 
proportion  of  cases  the  mental  defect  of  the  individual  has  been 
preceded  by  a  similar  defect  in  his  ancestors,  and  it  may  then  be 


24  Causation 

regarded  as  a  definite  instance  of  "  heredity  "  in  the  strict  meaning 
of  the  word.  But  this  is  by  no  means  always  the  case ;  indeed,  it  is  not 
even  the  rule,  and  in  my  experience  it  is  commoner  for  the  ancestors 
of  defectives  to  suffer  from  such  conditions  as  insanity,  epilepsy, 
dementia,  and  allied  psychopathological  states,  than  it  is  for  them 
to  be  actually  mentally  deficient.  It  is  obvious  that  the  repeated 
occurrence  of  such  conditions  as  these  in  a  family,  the  members  of 
which  live  in  an  environment  which  does  not  differ  essentially  from 
that  of  the  mentally  normal,  must  be  indicative  of  a  germinal 
variation ;  but  it  has  been  contended  that  it  is  erroneous  to  say  that 
the  defect  of  the  offspring  is  "  hereditary,"  since  it  is  not  identical 
with  the  ancestral  condition. 

I  must  confess  that  this  appears  to  me  to  indicate  some  con- 
fusion of  thought  as  to  the  real  nature  of  the  inheritance  underlying 
this  condition.  Heredity  has  been  aptly  defined  by  Professor 
J.  A.  Thomson*  as  "  the  genetic  relation  between  successive  genera- 
tions." The  medium  of  this  relationship  is  the  germ  cell;  but  the 
role  of  the  germ  cell  is  not  to  transmit  organs  and  tissues  already 
laid  down  in  miniature,  as  was  formerly  thought,  but  simply  to  hand 
on  certain  tendencies  to  development.  The  researches  of  Mendel,, 
and  those  subsequently  conducted  on  similar  lines,  have  shown 
that  it  is  highly  probable  that  the  germ  cell  contains  within  it  a 
series  of  forces,  or  "  determinants,"  which  direct  and  control  the 
development  of  each  separate  organ  and  tissue  of  the  body. 
Undoubtedly  the  influence  exerted  by  these  controlling  forces,  as 
we  may  regard  them,  is  very  considerable.  They  may,  on  the  one 
hand,  be  so  potent  that  a  certain  development  will  ensue  whatever 
the  nature  of  the  environment ;  on  the  other  hand,  the  tendency  to 
the  development  of  a  particular  quality  may  be  so  defective  that 
no  condition  of  the  environment  will  avail  to  bring  that  quality 
into  being.  Familiar  instances  of  this  are  seen  in  the  pigmented 
epithelium  of  the  negro  and  the  absence  of  pigment  of  the  albino. 
But  the  germ  cell  would  seem  to  be  the  seat  of  directive  forces, 
of  tendencies  to  development,  not  of  definite  qualities,  and  in  most 
instances  the  reaUzation  of  these  tendencies  depends,  in  more  or 
less  degree,  upon  the  particular  environment  attending  the  indi- 
vidual whilst  development  and  growth  are  taking  place. 

The  conclusion  to  which  I  have  come  is  that  amentia  must  be 
regarded,  not  as  due  to  the  absence  or  suppression  of  some  specific 
*   J.  A.  Thomson,  "  Heredity,"  London,  190S. 


General  Considerations  25 

germ  determinant,  but  as  resulting  from  a  diminished  germinal 
vitality,  in  consequence  of  which  development  tends  to  be  incom- 
plete. This  lessened  potentiality  is  especially  marked  in  that  con- 
stituent which  determines  the  development  of  the  central  nervous 
system — the  neuronic  determinant — but  it  is  often  more  widespread, 
and  then  affects  other  tissues  of  the  body  also.  In  other  words,  the 
inheritance  takes  the  form  of  a  neuropathic  diathesis,  or  an  innate 
predisposition  to  neuronic  imperfection ;  the  actual  manifestation 
of  this  innate  weakness,  however — that  is,  the  form  it  assumes — 
being  often  dependent  upon  the  nature  of  the  environment. 

In  investigating  the  family  histories  of  persons  suffering  from 
amentia,  insanity,  epilepsy,  or  other  manifestations  of  this  neuro- 
pathic diathesis,  it  is  not  unusual  to  find  that  whilst  many  members 
of  the  stock  present  psychopathic  or  neuropathic  anomalies,  there  are 
yet  others  who  do  not  appear  to  differ  from  the  ordinary  healthy 
members  of  mankind.  This  phenomenon  is  a  very  puzzling  one ;  it  is 
clear  that  germinal  impairment  is  present,  because  the  non-affected 
members  of  the  family  may,  and  frequently  do,  have  descendants 
who  are  markedly  abnormal.  It  is  possible  this  result  may  be  due  to 
the  transmission  taking  place  in  accordance  with  Mendel's  law,  and 
I  shaU  refer  to  this  point  presently ;  but  I  am  disposed  to  think  that 
the  suggestion  I  have  made  as  to  the  result  being  influenced  by  the 
environment  is  the  more  likely  explanation.  With  regard  to 
insanity,  for  instance,  there  is  no  doubt  that  whilst  a  predisposition, 
in  the  great  majority  of  cases,  is  essential,  yet  some  exciting  cause 
in  the  shape  of  ill-health,  intoxication,  severe  stress  or  strain,  is 
usually  necessary  to  determine  the  attack.  It  may  well  be  that  in 
a  family  characterized  by  the  neuropathic  diathesis  there  will  be 
several  members  whose  circumstances  and  mode  of  life  are  such 
that  the  necessary  excitant  does  not  occur,  with  the  consequence 
that  they  pass  muster  as  normal  individuals. 

'  In  the  case  of  amentia  it  seems  probable  that  we  have  to  do  with 
a  still  more  marked  germinal  impairment,  and,  as  a  matter  of  fact, 
although  what  may  be  termed  "  sporadic  "  cases  of  primary  idiocy 
frequently  occur,  a  close  examination  of  the  brothers  and  sisters 
of  the  affected  individual  will  usually  reveal  some  indications  of 
neuronic  abnormality.  It  seems  to  me  probable  that  here  also  the 
environment  plays  a  part,  and  that  the  result,  whether  mental 
adequacy  or  inadequacy,  very  often  depends  upon  some  adverse 
external  factor.     I  am  disposed  to  think  that  one  of  the  commonest 


26  Causation 

of  these  factors  is  the  physical  condition  of  the  mother  during 
gestation.  Obviously  this  is  a  matter  upon  which  it  is  often  diffi- 
cult to  obtain  precise  information ;  but  I  have  been  much  struck  by 
the  fact  that  many  isolated  cases  of  idiocy,  occurring  in  a  family 
with  only  a  slight  neuropathic  predisposition,  have  been  associated 
with  some  abnormal  condition  of  the  mother  whilst  she  was  carrying 
the  child. 

Apparently,  under  these  less-pronounced  conditions  of  germinal 
impairment,  the  germ  cell,  although  to  a  certain  extent  vitiated, 
is  stiU  capable  of  proceeding  to  the  perfect  structural  development 
of  the  embryo,  provided  no  untoward  circumstances  intervene  to 
further  embarrass  its  growth ;  but  should  there  happen  at  this  time 
any  deterioration  in  the  health  of  the  mother,  whereby  the  blood 
supplying  the  rapidly  growing  ovum  is  considerably  modified  in  its 
nutritive  qualities,  then  incomplete  development  is  very  likely  to 
occur.  As  far  as  my  experience  •  goes,  the  physical  condition  of 
the  mother  is  of  far  more  importance  than  her  mental  state,  except 
in  the  cases  in  which  this  may  modify  the  physical  condition. 

In  other  instances  the  same  result  is  attained  by  a  somewhat 
different  contributing  or,  as  it  may  be  termed,  exciting  factor. 
A  fairly  common  example  is  premature  birth ;  if  by  any  unfortunate 
chance  this  should  happen  where  there  are  already  present  pre- 
disposing factors,  even  if  slight,  the  child  is  extremely  likely  to 
show  some  mental  deterioration  as  compared  with  his  brothers  and 
sisters.  In  other  cases  prolonged  labour,  attended  with  more  or  less 
asphyxia,  may  act  in  the  same  manner;  the  temporary  obstruction 
of  the  cerebral  circulation  need  not  be  enough  to  give  rise  to  any 
actual  lesion,  or  in  a  healthy  child  to  produce  any  damage  whatever, 
but  in  the  present  instance  it  is  all  that  is  required  to  interfere  with 
the  perfect  development  of  the  nerve  cells,  and  some  degree  of  weak- 
mindedness  is  the  result. 

In  the  same  way  act  some  of  the  factors  occurring  after  birth, 
such  as  trauma,  convulsions,  rickets,  infectious  fevers,  meningitis, 
etc.  It  will  be  seen  that  in  the  larger  proportion  of  these  cases 
ancestral  defects  are  present,  and  the  exciting  factor  simply  acts 
as  the  last  straw  upon  the  already  enfeebled  developing  neuroblasts. 
This  it  may  do  by  causing  a  temporary  derangement  of  the  circula- 
tion or  metabolism  of  the  brain.  But  although  in  some  cases  an 
"  adverse  environment  "  (using  this  term  in  its  broadest  sense)  may 
be  the  sole  cause  of  amentia,  and  in  others  a  not  unimportant  con- 


General  Considerations  27 

tributing  cause,  the  net  result  of  my  inquiries  has  been  to  convince 
me  that  in  the  great  majority  of  persons  who  suffer  from  mental 
defect  the  real  underlying  condition  is  impairment  of  the  germ  cell 
of  the  nature  I  have  described. 

The  Origin  of  the  Germinal  Impairment. 

We  have  now  to  ask,  To  what  is  the  germinal  impairment  due  ? 
for  the  cause  of  this  will  be  the  realfons  et  origo  mali. 

There  is  probably  no  biological  problem  of  greater  interest  and 
importance,  and  about  which  less  is  known,  than  that  of  the  causa- 
tion of  germinal  variations — whether  of  a  progressive  or  retro- 
gressive nature.  The  explanation  usually  forthcoming  is  that  they 
are  spontaneous.  This  was  the  view  advanced  by  the  Royal  Com- 
mission, which  declared:  "  Both  on  the  ground  of  fact  and  of  theory 
there  is  the  highest  degree  of  probability  that  feeble-mindedness  is 
usually  spontaneous  in  origin — that  is,  not  due  to  influences  acting 
on  the  parent — and  tends  strongly  to  be  inherited." 

One  is  irresistibly  reminded  of,  and  unable  to  refrain  from  quoting, 
the  words  of  Huxley  on  this  matter.  In  his  "Essay  on  Perpetua- 
tion of  Living  Beings,"  Huxley  said:  "The  third  cause  that  I  have 
to  mention  is  a  very  extensive  one.  It  is  one  that,  for  want  of  a 
better  name,  has  been  called  '  spontaneous  variation  ' ;  which  means 
that  when  we  do  not  know  anything  about  the  cause  of  a  phe- 
nomenon, we  call  it  'spontaneous.'  In  the  orderly  chain  of  causes 
and  effects  in  this  world,  there  are  very  few  things  of  which  it  can 
be  said  with  truth  that  they  are  spontaneous.  Certainly  not  in 
these  physical  matters — in  these  there  is  nothing  of  the  kind ; 
everything  depends  on  previous  conditions.  But  when  we  cannot 
trace  the  cause  of  phenomena,  we  call  them  '  spontaneous.'  " 

To  say  that  amentia  is  "  spontaneous  "  in  origin,  therefore,  is  but 
a  confession  of  ignorance.  It  may  be  that  our  present  knowledge 
does  not  suffice  to  enable  us  to  answer  this  question ;  but  at  any  rate 
hypotheses  may  be  suggested  which,  if  they  serve  no  better  purpose, 
may  yet  be  of  service  in  stimulating  further  research. 

One  view,  which  has  probably  occurred  to  most  thinkers  on  the 
subject,  is  that  aments  may  be  the  products,  not  of  a  new  variation, 
but  of  the  perpetuation  of  a  strain  which  has  been  defective  from 
the  beginning.  As  is  now  generally  admitted,  j^ivilized  man  has 
arisen  from  a  simian  ancestry  by  the  gradual  evolution  of  a  more 
complex  and  higher  type  of  mental  organization.     In  other  words, 


28  Causation 

he  has  gradually  developed  a  series  of  mental  functions  and  faculties 
which  were  lacking  in  the  apes,  but  which  have  now  become  an 
essential  part  of  normal  mankind.  Accordingly  it  may  be  argued 
that  persons  suffering  from  mental  defect  are  not  so  in  consequence 
of  any  recent  germinaj^impairment,  or  of  any  reversion  even,  but 
simply  because  they  are  thedescendants  61  a  simian  strain  which 
was  fundamentally  incapable  of  evolving  beyond  a  certamphase. 

This  view  has  recently  been  put  forward  by  Dr.  Charles  B.  Daven- 
port,* who  says:  "  The  conclusion  is  forced  upon  us  that  the  defects 
of  this  germ  plasm  have  surely  come  all  the  way  down  from  man's 
apelike  ancestors,  through  two  hundred  generations  or  more.  The 
germ  plasm  that  we  are  tracing  remains  relatively  simple;  it  has 
never  gained,  or  only  temporarily,  at  most,  the  one  or  the  many 
characteristics  whose  absence  we  call  (quite  inadequately)  '  defects/ 
Feeble-mindedness  is  thus  an  uninterrupted  transmission  from  our 
animal  ancestry.     It  is  not  reversion;  it  is  direct  inheritance." 

Interesting  as  this  hypothesis  is,  it  is  one  to  which  I  cannot 
subscribe.  It  seems  to  me,  from  what  we  know  regarding  the  won- 
derful  "  adaptive  force  "  of  the  germ  plasm,  that  the  presence  in 
certain  stocks^of  such  an  inability  to  progress  would  denote  a 
distinct  germinal  abnormality,  so  that,  even  if  this  hypothesis  were 
granted,  the  problem  of  origm  is  not  explained ;  it  is  only  pushed 
back  "  two  hundred  generations  or  more."  But  if  this  evolutional 
incapacity  of  the  germ  plasm  were  really  present  in  certain  apes,  one 
cannot  help  wondering  how  their  descendants  evolved  into  human 
beings  at  all;  or,  having  so  evolved,  how  they  managed  to  survive 
amid  the  ruthless  natural  selection  which  was  certainly  operative 
in  the  dawn  of  human  existence.  It  is  doubtless  true,  as  Dr. 
Davenport  says,  that  a  continuous  trail  of  defects  may  sometimes 
be  traced  back  for  six  or  seven  generations ;  for  natural  selection  has 
for  some  time  been  rendered  nugatory  by  civilization,  and  defectives 
are  now  enabled  to  survive  who  would  formerly  have  perished;  but 
my  own  investigations  show  it  to  be  equally  true  that  germinal 
defect  may  make  its  appearance  in  a  stock  which,  so  far  as  can  be 
ascertained,  has  been  previously  sound. 

It  is  often  said  that  mental  defect  is  an  example  of  atavism  or 

reversion,  and  ingenious,  but  quite  incorrect,  parallels  are  drawn  of 

the  resemblances  between  the  intellectual  and  social  aptitudes  of 

an  ament  and  those  of  an  ape  or  a  prehistoric  man.     As  already 

*  "  The  Origin  and  Control  of  Mental  Defectiveness,"  1912. 


General  Considerations  29 

remarked,  I  look  upon  mental  defect  as  due  to  an  inherent  inability 
to  attain  to  the  developmental  stage  which  is  "  normal  "  in  the  race, 
and  it  is  quite  true  that  a  certain  psychological  likeness  may  exist 
between  some  aments  and  some  of  the  inferior  races  of  mankind, 
such,  for  instance,  as  the  South  Sea  Islanders  or  the  Bushmen;  but 
atavism,  in  the  words  of  De  Vries,  is  the  falling  back  to  a  prototype, 
that  is,  to  "  those  ancestors  from  which  a  form  is  known  to  be 
derived,"  and  it  by  no  means  follows  that  these  primitive  peoples 
are  in  the  direct  line  of  descent ;  they  may  equally  well  be  degenerate 
offshoots  from  the  main  stem,  and  I  certainly  very  much  doubt 
whether  the  phylogeny  of  civilized  man  was  ever  represented  by  a 
phase  of  evolution  comparable  with  that  of  mental  defect. 

In  short,  I  regard  the  germinal  variation  present  in  these  persons 
as  a  pathological  one;  as  being  oi  the  nature  of  a  vitiation,  which, 
instead  of  being  of  "  spontaneous  "  origin,  is  really  due  to  a  negation 
or  diminution  of  spontaneity.  How,  then,  is  this  impairment 
brought  about  ?     I  consider  that  it  is  primarily  due  to  the  action  of 

the  environment.  "^"^"^ 

This  view  is  one  which  I  have  held  and  stated  for  many  years; 
but  I  must  admit  that  it  is  regarded  as  highly  heterodox  by  many 
biologists,  besides  being  deprecated  by  the  Report  of  the  Royal 
Commission  on  the  Feeble-minded.  The  chief  objections  urged, 
against  it  are,  firstly,  that  "  the  teaching  of  biology  is  opposed  to 
the  possibility  of  such  a  connection  ";  and,  secondly,  that  the 
theory  may  be  traversed  by  many  arguments  to  the  contrary. 

«The  first  of  these  objections  is  an  a  priori  one,  and  apparently 
runs  thus:  That  since  the  germ  plasm  has  now  been  shown  by 
Weismann  to  be  "  continuous-"  and  not  manufactured  anew  by 
each  individual,  any  acquirements  of  the  somatic  cells  can  have  no 
influence  upon  it — therefore  the  germ  plasm  is  immutable.  Or,  in 
the  words  of  Weismann:  "It  is  an  inevitable  consequence  of  the 
theory  of  the  germ  plasm,  and  of  its  present  elaboration  and  exten- 
sion so  as  to  include  the  doctrine  of  determinants, that  somatogenic 
variations  are  not  transmissible."*  I  am  not  concerned  with  the 
transmission  of  such  acquirements  as  the  docking  of  dogs'  tails, 
the  nose-slitting  of  savages,  the  systematic  compression  of  the 
cranium,  or  circumcision,  because  I  do  not  consider  that  primary 
amentia  comes  into  this  category  at  all.  It  is  probable  that  such 
localized  acquirements  are  not  transmissible,  although  the  last  word 

*  A.  Weismann,  "  The  Germ  Plasm:  a  Theory  of  Heredity,"  1S93. 


30  Causation 

on  this  subject  has  not  yet  been  said,  as  has  been  well  shown  recently 
by  Professor  Hartog.*  The  question  is  whether  certain  particular 
morbid  states  of  the  body  may  so  affect  the  germ  plasm  as  to  bring 
about  pathological  variations;  also  whether  the  same  result  may 
follow  adverse  environmental  influences  acting  directly  upon  the 
germ  plasm. 

It  is  worthy  of  note  that  in  his  more  recent  works  Weismann 
himself  has  admitted  such  a  possibility,  and  not  only  is  it  incon- 
ceivable that  it  should  be  otherwise — that  the  germ  plasm  should 
live  a  charmed  life  amid  all  the  changes  taking  place  in  the  fluids 
by  which  it  is  bathed  and  upon  which  it  is  dependent  for  its  sus- 
tenance— ^but  many  facts  have  now  been  adduced  demonstrating 
that  such  modification  of  the  germ  plasm  does  actually  take  place. 
As  was  remarked  by  Beard,  |  who  has  made  a  most  valuable  research 
on  this  subject,  "  the  germ  cell  must  react  to  and  be  influenced  by 
its  environment." 

This  question  is  one  of  such  extreme  interest  and  importance 
that  it  win  not  be  out  of  place  to  refer  to  a  few  of  these  facts.  One 
of  the  earliest  inquiries  was  that  of  Dr.  Constantin  PaulJ  regarding 
the  effect  of  lead.  This  observer  found  that  out  of  32  pregnancies 
in  which  the  father  alone  suffered  from  lead-poisoning,  the  mother 
being  free  from  that  condition,  12  of  the  offspring  were  stillborn, 
8  died  during  the  first,  4  during  the  second,  and  5  during  the  third 
year  of  life,  whilst  another  one  died  later  in  childhood.  Similar 
data  regarding  workers  exposed  to  the  fumes  of  nitrate  of  mercury 
have  been  published  by  Lize.§  Out  of  12  pregnancies  in  which 
the  father  alone  was  exposed,  there  were  4  stillbirths;  of  the  remain- 
ing 8  children,  3  died  before  the  fourth  year,  and  only  one  could  be 
described  as  vigorous.  SuUivan  quotes  a  case,  described  by  Marfan, 
of  a  man  who,  after  having  two  healthy  children,  acquired  the 
cocain  habit,  and  whilst  suffering  from  the  symptoms  of  chronic 
poisoning  engendered  two  idiots. 

The  toxic  effects  of  alcohol  upon  growing  protoplasm  are  well 
known,  and  since  the  use  of  this  is  very  general  and  experimenta- 

*  M.  Hartog,  "  Problems  of  Life  and  Reproduction,"  191 3. 

f  J.  Beard,  "  A  Morphological  Continuity  of  Germ  Cells  as  a  Basis  of 
Heredity  and  Variation,"  Review  of  Neurology  and  Psychiatry,  vol.  ii.,  1904. 
See  also  J.  Loeb,  "  Experimental  Study  of  the  Influence  of  Environment  on 
Animals,"  1909.  Also  H.  M.  Vernon,  "  Variation  in  Animals  and  Plants," 
1903. 

X  Constantin  Paul,  "  Plumbism  and  the  Foetus,"  Paris,  1S61. 

§  Lize,  Union  Medicale,  1862. 


General  Considerations  31 

tion  with  it  is  comparatively  easy,  it  is  but  natural  that  it  should 
have  formed  the  subject  of  many  inquiries.  It  was  shown  by  Fere,* 
of  Paris,  that  the  effect  of  the  vapour  of  alcohol  upon  incubating 
eggs  was  to  produce  63  per  cent,  of  normal  births,  16  per  cent,  of 
incompletely  developed  embryos,  and  21  per  cent,  of  monstrosities 
and  chickens  of  "  idiotic  and  imbecile  grade."  If  the  experiments 
were  made  with  alcoholic  solutions  of  absinthe,  the  effects  were  stiU 
more  marked,  there  being  but  25  per  cent,  of  normal  births,  31  per 
cent,  of  incompletely  developed,  and  44  per  cent,  of  abnormal  and 
defective  chicks.  Combemalef  found  that  pups  begotten  on  a 
healthy  bitch  by  an  alcoholized  dog  were  congenitally  feeble,  and 
showed  a  marked  degree  of  asymmetry  of  the  brain. 

One  of  the  most  recent  pieces  of  work  in  this  field  is  that  by 
StockardJ  upon  guinea-pigs.  Out  of  24  matings  of  alcoholized 
fathers  with  normal  mothers,  14  matings  gave  early  abortions  or 
were  negative,  5  matings  gave  stillborn  litters  (in  all,  8  young), 
5  matings  gave  living  litters  (in  all,  12  young) ;  of  the  12  living 
young,  7  died  in  convulsion  soon  after  birth,  and  5  survived.  The 
net  result  of  these  24  matings,  therefore,  was  5  surviving  offspring, 
or  only  as  many  as  might  have  been  expected  from  a  single  pairing 
of  two  healthy  animals,  and  at  the  age  of  two  months  these  5  sur- 
vivors were  only  half  the  usual  size. 

Dr.  Ed.  Bertholet,§  pursuing  a  similar  investigation,  but  by  dif- 
ferent means,  made  a  series  of  microscopical  examinations  of  the 
testes  of  120  men,  80  of  whom  were  notoriously  alcoholic.  He  was 
able  to  demonstrate  very  clear  differences  between  the  alcoholics 
and  the  non-alcoholics,  and  says:  "  The  hurtful  influence  of  chronic 
alcoholism  upon  sexual  glands  is  not  to  be  denied." 

Similar  results  have  been  obtained  in  the  case  of  other  toxic 
agents.  Gheorghiu||  "  made  an  extended  inquiry  into  the  health 
conditions  of  the  parents  in  a  long  series  of  monstrous  births 
occurring  in  the  Paris  hospitals,  and  his  statistics  show  most  con- 
vincingly that  there  is  a  direct  relationship  between  parental  tuber- 

*  Fere,  Comptes  Rendus,  Societe  de  Biol.,  Paris,  vol.  lii. 

t  Quoted  by  Dr.  W.  C.  Sullivan  in  "  Alcoholism,"  p.  185,  1906. 

I  Quoted  in  an  address  on  "  A  Study  in  Eugenics,"  by  Prof essor  J .  G.  Adami, 
which  contains  much  interesting  information  on  the  modification  of  the 
germ  plasm  by  the  environment  (Lancet,  November  2,  1912). 

§  Ed.  Bertholet,  "  On  the  Atrophy  of  the  Human  Testicle  under  the  Influ- 
ence of  Chronic  Alcoholism,"  Centralblatt  fiir  Paihologie  u.  Pathol.  Anatotnie, 
Band  xx.,  No.  23,  1909. 

II  Quoted  from  Professor  J.  G.  Adami,  op.  cit. 


32  Causation 

culosis,  syphilis,  and  acute  infections  affecting  one  or  other  parent, 
and  these  gross  examples  of  maldevelopment."  Carriere*  inocu- 
lated a  series  of  male  and  female  guinea-pigs  with  the  toxins  of  the 
tubercle  baciUus.  In  the  cases  where  the  male  only  was  inoculated 
there  were  i6-6  per  cent,  of  stillbirths,  lo  per  cent,  of  deaths  under 
ten  days  of  age,  and  only  73-3  per  cent,  of  survivals. 

Lustigj  ascertained  that  when  cocks  by  a  process  of  slow  intoxica- 
tion with  abrin  had  been  rendered  immune  to  ordinary  fatal  doses 
of  that  drug,  their  offspring  showed  clear  traces  of  the  influence  of 
the  paternal  poisoning,  being  few  in  number,  of  low  vitality,  stunted, 
and  often  deformed  in  growth.  Similar  results  were  obtained  by 
Watsonj  in  the  case  of  guinea-pigs.  It  may  be  said  that  in  many 
of  the  preceding  cases  the  evil  effects  were  still  more  marked  when 
both  parents  had  been  exposed  to  the  toxic  agent ;  but  as  the  action 
through  the  mother  may  not  be  wholly  germinal,  but  partly  en- 
vironmental, I  have  given  statistics  of  paternal  infection  only. 

But  the  germ  plasm  may  be  modified  by  other  agencies  than 
poison.  Srunner  has  succeeded  in  producing  important  racial 
alterations  in  mice  by  means  of  temperature;  Bordage  has  done 
the  same  with  peach-trees,  and  Tower  §  with  beetles;  whilst  Mac- 
dougal  §  has  brought  about  new  varieties  of  plants  as  a  result  of 
injecting  chemical  agents  into  the  immature  ovaries.  Lastly, 
mention  may  be  made  of  the  recent  researches  of  Professor  Franz 
Boaz,||  which  show  that  in  the  descendants  of  immigrants  to 
America  there  are  gradually  produced  definite  changes  of  racial  type 
which  Boaz  considers  can  only  be  due  to  the  action  of  the  environ- 
ment. 

In  view  of  these  and  similar  facts  which  are  now  forthcoming, 
it  is  absurd  to  contend  that  the  germ  plasm  is  immutable.  There  is 
the  clearest  evidence  that  it  may,  and  does,  undergo  modification 
by  the  environment,  and  I  have  thought  it  well  to  refer  to  this  at 
some  length  for  the  reason  that  the  fact  is  one  of  great  importance 
in  the  problem  of  the  causation  of  that  pathological  germinal  varia- 
tion which  lies  at  the  root  of  mental  deficiency,  and  which  has  been 
alleged  to  be  "  spontaneous."     I  venture  to  think  that,  in  view  of 

*  Carriere,  Archives  de  Midecine  Experimentale,  No.  12,  1900. 
t  Lustig,  Ceniralblait  fiir  Pathologie,  No.  15,  1904. 

I  Watson,  British  Medical  Journal,  vol.  ii.,  1905. 

§  Publications  of  the  Carnegie  Institute,  Washington,  1905-6. 

II  F.  Boaz,  "  Changes  in  the  Bodily  Form  of  the  Descendants  of  Immi- 
grants," London,  191 2. 


General  Considerations  33 

this  evidence,  the  a  priori  objections  of  the  biologists  fall  to  the 
ground.  If  the  ascertained  facts  do  not  fit  in  with  the  theory,  so 
much  the  worse  for  the  theory ;  whilst  the  arguments  adduced  to  the 
<:ontrary,  chiefly  of  an  a  priori  nature  too,  cease  to  have  any  real 
weight  in  the  light  of  the  facts  which  are  now  known. 

I  hold  that  primary  amentia  is  a  manifestation  of  a  pathologicalj 
germinal  variation  which  has  been  produced  by  the  environment,! 
and  that  the  germinal  change  is  of  the  nature  of  a  vitiation.  That 
is  to  say,  it  consists  of  an  impairment  of  the  intrinsic  potentiality 
for  development,  which  may  be  widespread  and  affect  the  germ 
cell  as  a  whole,  or  which  may  be  less  extensive  and  confined  to  the 
neuronic  determinant.  At  the  beginning,  in  most  instances,  the 
latter  is  probably  the  case,  and  the  initial  change  is  but  slight.  It 
shows  itself  merely  in  a  diminished  function  and  durability  of  the 
higher,  and  therefore  an  increased  excitability  of  the  lower,  cerebral 
neurones,  and  is  revealed  clinically  as  neurasthenia,  hysteria, 
migraine,  and  the  milder  forms  of  epilepsy.  We  may  say,  in  fact, 
that  these  states  are  the  first  indications  of  the  presence  of  the 
psychopathic  diathesis.  Should  the  adverse  environment  continue, 
or  should  a  person  so  affected  mate  with  one  similarly  tainted,  then 
in  the  next  generation  the  neuronic  durability  will  be  further  dimin- 
ished, and  the  instability  accentuated,  so  that  insanity,  the  graver 
iorms  of  epilepsy,  and  early  dementia  make  their  appearance.  If 
the  process  is  further  continued,  the  third  generation  will  often  be 
•characterized  by  a  tendency  to  defects  of  anatomical  structure,  and 
there  will  be  a  strong  probability  of  one  or  more  of  the  offspring 
suffering  from  amentia.  Should  this  germinal  impairment  be  ac- 
■companied  by  any  untoward  circumstances  during  the  growth  of 
.  the  embryo,  like  those  presently  to  be  described,  this  probability 
will  become  a  tolerable  certainty.  Degeneracy  is  here  well  estab- 
lished, and  the  well-known  stigmata,  indicative  of  an  extensive 
germinal  change,  are  usually  abundant.  Finally,  a  condition  of  gross 
idiocy  appears,  with  complete  sterilitj^  and  the  family  becomes 
extinct. 

It  is  not  suggested  that  the  three  grades  of  mental  disease  above 
described  are  necessarily  restricted  to  three  successive  generations. 
All  the  degrees  may  exist,  and  frequently  do,  amongst  members  of 
one  and  the  same  generation,  and  I  think  this  result  is  largely  de- 
•  pendent  upon  the  conditions  of  intra-  or  early  extra-uterine  life. 
JNeither  do  I  wish  to  infer  that  the  neuropathic  heritage  always 

3 


34  Causation 

culminates  in  amentia  in  the  third  generation.  It  may  be  so  modi- 
fied by  admixture  with  healthy  plasm  that  this  end  may  be  much 
longer  delayed;  indeed,  it  may  possibly  be  eradicated  in  some  in- 
stances. On  the  other  hand,  it  occasionally  happens  that  the  initial 
change  is  so  severe  that  it  results  at  once  in  gross  idiocy.  This, 
however,  is  exceptional,  and  from  a  close  study  of  a  very  large 
number  of  family  histories  I  am  disposed  to  think  that,  on  the  whole, 
the  above  outline  is  a  tolerably  accurate  picture  of  the  successive 
steps  in  the  production  of  amentia.  We  may  therefore  say  that 
this  latter  condition  represents  the  final  manifestation  of  a  progres- 
sive psychopathic  diathesis. 

Thus,  in  persons  suffering  from  migraine,  neurasthenia,  and  hys- 
teria, it  is  uncommon  to  find  marked  ancestral  nervous  or  psychic 
disorder;  whilst  a  history  of  the  parents  suffering  from  alcoholism, 
phthisis,  and  modes  of  life  attended  with  severe  stress  and  strain  is 
frequent./  In  the  next  grade — the  milder  forms  of  epilepsy — neuro- 
pathic inheritance  becomes  more  marked,  and  in  the  severe  forms  of 
this  affection  it  is  present,  according  to  Sir  William  Gowers,  in  about 

35  per  cent,  of  cases.  In  the  next  grade — insanity — Sir  Thomas 
Clouston  and  Dr.  J.  S.  Bolton  have  found  neuropathic  inheritance 
in  from  50  to  60  per  cent,  of  cases,  whilst  in  amentia,  as  I  shall 
presently  show,  it  occurs  in  80  per  cent,  of  cases. 

The  fact  that  the  mating  of  two  persons  with  pronounced  neuro- 
pathic inheritance  is  often  followed  by  an  accentuation  in  degree 
and  earlier  appearance  in  time  (ante-dating)  of  the  abnormality  in 
the  offspring,  has  long  been  recognized  clinically  by  psychiatrists, 
and  has  been  well  shown  by  such  authorities  as  Sir  T.  S.  Clouston 
and  Sir  George  Savage.  In  this  connexion  the  words  of  the 
former,  in  his  recent  most  interesting  work  on  "  Unsoundness  of 
Mind,"  are  well  worth  quoting.  Sir  T.  S.  Clouston*  says:  "  I  have 
traced  the  same  series  of  hereditar}^  morbid  sequences  through  the 
stages  of  mental  hyperactivity,  hypersesthesia,  diminished  inhibition, 
instabihty,  melancholia,  mania,  alternation,  insanity,  secondary 
dementia,  down  to  idiocy,  each  of  these  appearing  in  each  successive 
generation."  It  may  also  be  mentioned  that  fifty  years  ago  Morel, f 
the  great  French  author  on  the  subject  of  degeneracy,  came  to  the 
conclusion  that  the  initial  stages  of  the  psychopathic  diathesis  were 
manifest  as  a  tendency  to  neurasthenia,  mild  neuroses  and  psychoses,. 

•  T.  S.  Clouston,  "  Unsoundness  of  Mind,"  1911. 

f  B.  A.  Morel,  "  Traite  des  Degenerescences,"  Paris,  1857. 


General  Considerations  35 

and  peculiarities  of  conduct  and  behaviour,  and  he  laid  down  very 
clearly  that  these  might  be  produced  by  the  action  of  the  environ- 
ment.    His  work  is  one  of  very  great  interest,  and  well  worth  study. 

With  regard  to  all  those  adverse  conditions  of  the  environment 
which  are  responsible  for  this' germinal  variation,  our  knowledge  is 
still  very  incomplete.  It  is  Ukely  that  factors  have  acted,  and  may 
still  be  at  work,  of  which  at  present  we  know  nothing,  and  that 
many  forms  of  excess,  intoxications  and  auto-intoxications  conse- 
quent on  faulty  modes  of  life,  may  be  capable  of  impairing  the 
vitality  of  the  germ  plasm,  and  so  initiating  that  early  change  which, 
if  unchecked,  will  culminate  in  amentia.  But  the  close  association 
which  exists  between  the  neuropathic  diathesis  and  alcoholism  and 
tuberculosis,  together  with  the  experimental  work  which  has  been 
conducted  regarding  these  agencies,  leads  me  to  the  opinion  that 
they,  at  any  rate,  have  an  important  influence. 

It  would  be  of  extreme  value  could  we  ascertain  the  precise  modus 
operandi  of  these  deleterious  agencies.  Do  they  act  by  depriving 
the  neuronic  determinant  of  certain  essential  food  constituents,  or 
have  they  a  direct  toxic  effect  ?  Perhaps  the  action  is  different  in 
different  circumstances,  but  it  would  appear  that  the  term  "  blasto- 
phoria  "  (germ  corruption)  made  use  of  by  Forel  is  not  inappro- 
priate. In  view  of  the  fact  that  in  man  the  nervous  system  is  at 
once  the  most  highly  developed,  most  complex,  and  most  recently 
evolved,  it  is  not  surprising  that  it  should  be  the  most  vulnerable 
to  these  changes. 

'  The  Transmission  of  the  Germinal  Defect. 

The  question  now  arises,  What  are  the  laws  governing  the  trans-i 
mission  of  this  germinal  defect  ?  Since  the  rediscovery  of  the  work 
of  Gregor  Mendel,  many  inquiries  have  been  made  with  the  object 
of  determining  whether  hereditary  abnormalities  and  defects  in 
man  are  transmissible  in  accordance  with  Mendel's  laws.  In  the 
case  of  some  abnonnalities,  such  as  brachydactyly,  colour-blindness, 
congenital  cataract,  night-blindness,  etc.,*  there  is  strong  reason 
for  thinking  that  they  are  so  transmitted.  Is  this  the  case  with  the 
neuropathic  diathesis  ? 

*  For  further  information  on  this  subject  see  the  valuable  work  of  Dr. 
Nettleship,  Bowman  Lecture,  Transactions  of  the  Ophthalmic  Society,  1909; 
Professor  Bateson  on  "  Mendel's  Principles  of  Heredity,"  1909;  and  Professor 
Punnett  on  "  Mendelism,"  1907. 


3  6  Causation 

One  of  the  most  recent  pieces  of  work  on  this  subject  is  that  of 
Rosanoff  and  Orr,*  of  America.  The  authors  conclude  a  very  inter- 
esting paper,  which  is  illustrated  with  a  number  of  family  pedigree 
charts,  with  the  words:  "  It  would  seem,  then,  that  the  fact  of  the 
hereditary  transmission  of  the  neuropathic  constitution  as  a  reces- 
sive trait,  in  accordance  with  the  Mendehan  theory,  ma}-  be  regarded 
as  definitely  established."  A  similar  conclusion  was  arrived  at  by 
Davenport  and  Weeksf  in  a  very  careful  study  of  pedigrees  of  the 
inmates  of  the  New  Jersey  State  village  for  epileptics.  But  the 
difficulties  and  sources  of  possible  fallacy  attendant  upon  such 
inquiries  are  so  great  that  one  must  accept  these  conclusions  with 
considerable  reserve.  In  the  first  place  man  is  not  a  very  suitable 
subject  for  the  study  of  Mendelism  at  aU,  owing  to  the  small  number 
of  his  offspring;  added  to  which  so  many  of  the  manifestations  of 
the  neuropathic  diathesis  depend  upon  the  nature  of  the  early 
education,  the  physical  health,  and  the  conditions  and  mode  of  life 
pursued  by  the  individual,  that  the  precise  enumeration  of  those 
who  are,  or  are  not,  affected  with  hereditary  taint  is  exceedingly 
dif&cult.  An  individual  may  be  the  victim  of  the  neuropathic 
diathesis,  and  yet  pass  through  life  apparently  normal  owing  to  the 
absence  of  the  necessary  excitant.  And  a  numerical  estimate  is 
essential  to  determine  whether  this  transmission  is  or  is  not  ]\Ien- 
dehan.  I  am  disposed  to  think,  therefore,  that  many  more  inquiries 
wiU  have  to  be  made  before  these  conclusions  can  be  regarded  as 
"  established."  The  utmost  we  can  do  at  present  is  to  take  note  of 
facts,  leaving  the  enunciation  of  laws  until  such  time  as  a  suf&cient 
array  of  facts  is  available.  The  following  are  the  facts  which  have 
come  within  my  own  experience  with  regard  to  this  transmission : 

Firstly,  that  if  both  parents  are  healthy  and  free  from  neuropathic 
taint,  their  offspring  is  healthy. 

Secondly,  that  if  one  or  both  parents,  although  free  from  neuro- 
pathic inheritance,  suffer  from  alcoholism,  severe  tuberculosis, 
plumbism  (and  possibly  other  poisons),  the  nervous  S3-stem  of  the 
offspring  tends  to  be  more  unstable  and  less  durable  than  that  of 
the  offspring  of  healthy  parentage. 

Thirdly,  that  the  mating  of  such  neurotic  offspring  with  healthy 

*  A.  J.  Rosanofi  and  Florence  J.  Orr,  "  A  Study  of  Heredity  in  Insanity 
in  the  Light  of  the  Mendehan  Theory,"  No.  5  Bulletin,  Eugenics  Record  Office, 
New  York,  191 1. 

f  C.  B.  Davenport  and  D.  F.  Weeks,  No.  4  Bulletin,  Eugenics  Record  Office, 
New  York,  191 1. 


General  Considerations  37 

and  untainted  individuals  may,  after  a  few  generations,  eradicate 
the  nervous  abnormality,  but  that  the  mating  with  individuals  of 
like  constitution  tends  to  produce  offspring  with  an  accentuation  of 
the  abnormality,  and  an  increased  predisposition  to  .more  serious 
neuropathic  manifestations. 

Fourthly,  that  the  mating  of  two  individuals  of  such  marked 
neuropathic  inheritance  yields  offspring  in  whom  there  is  a 
definite  tendency  to  imperfection  of  brain  development,  or  mental 
defect. 

Fifthly,  that  the  mating  of  two  mentally  defective  individuals 
yields  offspring  who  are  all  defective. 

Amentia  directly  due  to  External  Causes. 

Hitherto  I  have  dealt  with  primary  amentia  only — that  is,  with 
that  form  which  is  innate  and  due  to  germinal  impairment.  It  is 
now  necessary  to  say  a  few  words  regarding  that  small  proportion 
of  cases  of  secondary  amentia  in  which  the  germ  plasm  is  healthy, 
but  in  which  the  growth  of  the  brain  has  been  arrested  by  some 
external  factor  acting  after  conception  has  taken  place.  Such  con- 
dition is  a  somatic  modification. 

It  has  been  stated  that,  although  adverse  conditions  of  the 
environment  are  present  in  a  considerable  number  of  cases  of 
amentia,  the  proportion  in  which  they  are  the  direct  and  sole  cause 
is  relatively  small^probably  at  the  most  not  more  than  10  to 
15  per  cent.  To  this  extent,  however,  the  environment  does  seem 
capable  of  producing  amentia,  although  in  many  instances  this  is 
but  the  incidental  phase  of  a  process  which  is  really  degenerative 
and  of  which  the  end  is  dementia.  These  factors  will  be  described 
in  detail  presently,  and  since  many  of  them  are  pathological  pro- 
cesses which  result  in  a  gross  lesion  of  the  brain,  it  will  be  more 
convenient  to  describe  the  manner  of  their  action  together  with 
their  clinical  characteristics.  A  few,  however,  give  rise  to  a  general 
arrest  of  development  without  any  naked-eye  lesion,  and  these  may 
briefly  be  referred  to  in  this  place. 

Under  normal  conditions  the  brain  of  the  child  grows  with  ex- 
treme rapidity  during  the  first  few  years  of  life.  This  is  in  conse- 
quence of  its  inherent  capacity  for  growth  plus  the  stimulation  of 
sensory  impressions  and  the  presence  of  an  adequate  quantity  and 
quality  of  blood.  This  inherent  capacity  may  be  normal,  but  the 
necessary  stimulation  or  food  so  deficient  that  the  gradual  unfold- 


38  Causation 

ing  of  the  mental  faculties  does  not  take  place,  or  takes  place  so 
tardily  that  some  degree  of  backwardness  is  the  result.  Cases  of 
this  kind,  in  which  development  is  delayed,  are  extremely  common, 
and  it  usually  happens  that  upon  the  removal  of  the  cause  mental 
expansion  rapidly  ensues.  Should  the  adverse  conditions  continue 
sufficiently  long,  however,  the  brain  cells  seem  in  some  cases  unable 
to  recover;  the  mind  never  makes  up  the  lost  ground,  and  some 
degree  of  mental  deficiency  is  the  result.  In  my  experience  actual 
idiocy  is  never  caused  in  this  way,  and  the  resulting  defect  is  of 
comparatively  mild  degree  only;  it  is  nevertheless  a  true  amentia. 
I  do  not  think  that  cases  of  this  kind  are  ver}^  common,  but  they 
form  a  certain  small  percentage  of  the  adult  feeble-minded  and  of 
mentally  defective  school-children,  particularly  in  the  large  towns. 
The  cause  seems  usually  to  be  that  combination  of  factors — drink, 
dirt,  and  depravity — ^which  go  to  make  up  slum  life  in  its  worst 
form. 

With  regard  to  the  influence  of  slum  life  and  all  its  associated 
conditions  in  producing  amentia,  it  is  necessary  to  sound  a  note  of 
warning.  It  does  happen  sometimes  that  the  real  mental  defectives 
of  our  large  towns  hail  from  the  slums,  although  I  do  not  think  such 
is  disproportionately  the  case.  Still,  a  sufficient  number  of  de- 
fective children  come  from  such  areas  to  make  the  superficial  in- 
quirer, content  with  that  which  is  apparent,  jump  to  the  conclusion 
that  the  pernicious  environment  is  therefore  the  cause  of  their 
defect.  My  own  inquiries  have  convinced  me  that  in  the  great 
majority  of  these  sliun  cases  there  is  a  pronounced  morbid  inheri- 
tance, and  that  their  environment  is  not  the  cause,  but  the  result, 
of  that  heredity.  The  neuropath  is  one  who  is  at  an  economic 
disadvantage  in  the  struggle  for  existence.  He  frequently  finds  it 
difficult  to  hold  his  place,  and  he  is  often  possessed  of  careless, 
improvident,  and  intemperate  propensities,  which  cause  him  to 
fritter  away  the  money  he  does  earn.  He  is  on  the  downgrade. 
No  wonder,  then,  that  he  drifts  to  the  slums. 


The  Causal  Factors  of  Amentia. 

Having  now  dealt  with  the  production  of  amentia  from  a  general 
standpoint,  I  propose  to  refer  to  the  individual  factors  which  have 
a  causal  relationship  to  this  condition.  It  will  be  obvious  that 
most  of  these  are  really  factors  of  the  environment;  nevertheless 


The  Causal  Factors  of  Amentia 


39 


their  effect  is  very  different.  Some  of  them  are  operative  upon  the 
germ  plasm,  giving  rise  to  pathological  variations,  which  are  trans- 
missible in  accordance  with  the  laws  of  heredity,  so  that  the  defect 
becomes  innate.  Others  only  affect  the  offspring  after  fertilization 
has  taken  place;  their  effects  are  therefore  of  the  nature  of  somatic 
modifications  and  are  probably  not  transmissible.  For  these  reasons 
it  will  be  convenient  to  divide  these  etiological  factors  into  two 
groups,  as  follows: 

A.  Germ  Variation. 

Factors  indicative  of,   or   producing,   a   Variation  of  the 

Germ  Plasm. 

1.  Neuropathic  inheritance. 

2.  AlcohoUsm. 

3.  Tuberculosis. 

4.  Syphilis. 

5.  Consanguinity. 

6.  Age  of  parents. 

B.  Somatic  Modification. 

Factors  acting  directly  upon  the  Offspring. 

Abnormal   conditions   of   the   Mother   during   Preg- 
nancy—(i)  Mental,  (2)  Physical. 
Injuries,  etc.,  to  the  Fcetus. 

Abnormalities  of  Labour. 

Primogeniture.  v 

Premature  Birth. 

Traumatic. 
Toxic. 
Convulsive. 
Nutritional. 

Factors  indicative  of,   or    producing,   Germinal  Variation. 
I.  Neuropathic  Inheritance. 

It  is  agreed  by  all  who  have  studied  this  question  that  the  most 
frequent  proximate  cause  of  amentia  is  the  neuropathic  diathesis. 
As  I  have  already  explained,  this  may  be  produced  by  many  factors, 
all  of  which  will  be  considered  in  this  section.  In  the  present 
instance,  however,  I  am  alluding  to  those  cases  in  which,  however 
produced,  it  already  exists  in  the  family,  as  shown  by  the  repeated 
occurrence  of  such  neuropathological  states  as  amentia,  insanity, 
dementia,  epilepsy,  paralysis,  or  various  neuroses.     My  inquiries 


[a)   Before  Birth 

u. 

(b)   During  Birth 

!■; 

(c)   After  Birth 

'I. 
2. 

4°  Causation 

showed  that,  in  a  series  of  over  200  patients  whose  family  histories 
were  thoroughly  investigated,  over  80  per  cent,  were  the  descendants 
of  a  pronounced  neuropathic  stock.  In  64*5  per  cent,  the  ancestral 
conditions  took  the  form  of  amentia,  insanity,  or  epilepsy;  whilst 
in  18  per  cent,  they  consisted  in  a  marked  family  tendency  tO' 
paralysis,  cerebral  haemorrhages,  or  various  neuroses  and  psychoses. 
Somewhat  similar  results,  showing  the  great  prevalence  of  this 
factor,  have  been  obtained  by  other  investigators.  For  instance, 
in  England  it  was  found  by  Beach  and  Shuttleworth*  that  insanity, 
epilepsy,  and  allied  neuroses  were  well  marked  in  the  ancestors  of 
24  per  cent,  of  the  patients  they  examined;  but  Dr.  Caldecott  con- 
siders that  70  to  75  per  cent,  have  neuropathic  antecedents.  Dr. 
Lapagef  found  that  48-4  per  cent,  of  feeble-minded  children  in  the 
Manchester  special  schools  had  a  neuropathic  inheritance,  and  he 
states  that  had  it  been  possible  to  obtain  all  details,  this  percentage 
would  probably  have  been  increased.  Dr.  W.  A.  Pottsi  ascertained 
the  presence  of  such  inheritance  in  45-6  per  cent,  of  children  attend- 
ing the  Birmingham  special  schools,  and  Dr.  Henry  Ashby  found  it 
to  occur  in  75  per  cent,  of  his  cases.  In  America  a  Commission 
appointed  by  the  Legislature  of  Connecticut  found  neuropathic 
heredity  to  be  the  undoubted  cause  in  43  per  cent.  But  Dr. 
Goddard,  of  Vineland,  as  the  result  of  careful  personal  inquiries, 
found  heredity  present  in  65  per  cent,  of  cases.  In  Germany  Koch§ 
came  to  the  conclusion  that  it  accounted  for  60  per  cent,  of  cases. 
In  Switzerland  (Canton  of  Berne)  the  census  of  1893  showed  that 
heredity  was  present  in  55  per  cent,  of  idiots;  whilst  in  Nonoay 
Ludwig  Dahl  found  it  to  occur  in  50  per  cent,  of  cases. 

It  is  seen  that  my  own  results  are  considerably  higher  than  those 
obtained  by  most  other  observers,  and  it  is  necessary  to  explain 
the  discrepancy.  I  believe  it  to  be  entirely  a  question  of  the 
method  adopted.  Most  statistics  relating  to  this  subject  have  been 
compiled  from  case-books  or  official  returns,  and  although  by  this 
means  an  immense  amount  of  material  is  available,  the  details 
must  necessarily  be  lacking  in  the  accuracy  and  completeness 
obtainable  by  a  personal  inquiry.     Again  and  again  have  I  dis- 

*  Beach  and  Shuttleworth,  CUfford  AUbutt's  "  System  of  Medicine," 
vol.  vii. 

t  C.  P.  Lapage,  "  Feeble-mindedness  in  Children,"  1911. 

%   W.  A.  Potts,  British  Journal  of  Children's  Diseases,  March,  1909. 

§  J.  L.  A.  Koch,  "  Zur  Statistik  der  Geisterkrankheiten  in  Wiirtemberg, 
und  der  Geisterkr.  iiberhaupt,"  Stuttgart,  1878. 


The  Causal  Factors  of  Amentia  41 

covered,  by  a  little  questioning,  a  well-marked  history  of  insanity 
of  which  no  record  whatever  existed  in  the  official  case-book;  and 
it  is  my  opinion  that,  although  statistics  based  upon  these  may  be 
of  value  as  showing  the  relative  importance  of  the  different  factors, 
they  are  practically  valueless  as  an  indication  of  the  precise  extent 
to  which  these  factors  occur. 

It  was  the  recognition  of  the  incomplete  and  unsatisfactory  details 
in  the  case-books,  including  some  of  those  which  have  formed  the 
basis  for  previous  generalizations  on  this  matter,  which  decided  me 
to  conduct  an  independent  and  personal  inquiry  into  the  causation 
of  amentia.  Unfortunately,  the  taking  of  a  reliable  family  history 
involves  much  time  and  trouble.  It  is  essential  to  gain  the  con- 
fidence of  the  relatives,  and  it  is  often  necessary  to  interview  several 
members  of  the  family  before  all  the  requisite  details  can  be  elicited. 
Moreover,  family  histories  can  rarely  be  considered  satisfactory 
unless  they  include  particulars  of  three  generations.  For  these 
reasons  a  personal  inquiry  of  this  kind  can  only  be  based  upon  a 
comparatively  small  number  of  cases;  but  what  is  lost  in  quantity 
is  more  than  compensated  for  by  accuracy  and  wealth  of  detail. 
As  a  matter  of  fact,  although  I  have  had  access  to  several  thousands 
of  cases,  in  only  a  little  over  200  were  the  details  sufficiently  com- 
plete to  be  of  use. 

It  is  very  interesting  to  note  that  this  method  has  recently  been 
adopted  in  America  with  conspicuous  success'."  The  Eugenics 
Section  of  the  American  Breeders'  Association*  have  now  a  regular 
staff  of  specially  trained  and  qualified  "  field  workers,"  and  the 
bulletins  issued  from  their  record  office  already  bear  much  promise 
of  important  sociological  results.  The  same  method  has  been 
pursued  by  Dr.  Henry  H.  Goddard,t  Superintendent  of  the  Vin eland 
State  Institution  at  New  Jersey,  who  has  by  this  means  been  able 
to  collect  most  valuable  pedigrees  of  the  mentally  defective;  also 
by  Dr.  Henry  A.  Cotton,  J  Medical  Director  of  the  New  Jersey  State 
Hospital  of  Trenton,  who  has  now  collected  a  large  number  of 
pedigrees,  giving  particulars,  on  an  average,  of  200  or  more  in- 
dividuals in  each  family.     In  Germany  inquiries  on  similar  fines 

*  See  Bulletins  issued  from  Eugenics  Record  Office,  Cold  Spring  Harbour, 
New  York. 

t  See  an  article  by  Dr.  H.  H.  Goddard  on  "  Heredity  of  Feeble-minded- 
ness,"  American  Breeders'  Alagazine,  vol.  i..  No.  3. 

t  H.  A.  Cotton,  "  Problems  in  Study  of  Heredity  in  Mental  Disease," 
American  Journal  of  Insanity,  July,  1912. 


42  Causation 

are  being  conducted  by  the  indefatigable  Dr.  E.  Riidin,*  Oberarzt 
of  the  Royal  Psychiatric  Klinic  in  Munich,  who  personally  goes  into 
the  field  for  several  months  each  year  to  collect  data. 

With  regard  to  my  own  cases,  the  following  additional  facts  may 
be  cited:  Of  124  patients  with  neuropathic  heredity,  it  was  present 
in  the  direct  line  only  in  58;  in  the  collaterals  only  in  26;  and  in 
both  direct  and  collaterals  in  40  cases.  It  was  present  on  the  paternal 
side  only  in  61;  on  the  maternal  only  in  39;  and  on  both  sides 
in  24  cases. 

It  is  seen  from  these  latter  figures  that  paternal  is  more  common 
than  maternal  inheritance.  Voisin  found  the  reverse  to  be  the  case. 
It  is  therefore  probable  that  a  sufficiently  large  series  of  cases  would 
show  that  there  was  little  difference  in  this  respect.  In  my  cases 
the  transmission  occurred  equally  to  the  same  and  to  the  opposite 
sex. 

It  would,  of  course,  be  desirable  that  these  statistics  should  be 
compared  with  similar  ones  regarding  the  mentally  normal  popula- 
tion. This  has  recently  been  done  by  Dr.  Ettie  Sayer,-]-  who  found 
that  in  the  families  of  100  mentally  defective  children  there  was  a 
family  history  of  insanity  in  31,  of  epilepsy  in  11,  and  that  a 
parent  was  mentally  defective  in  34  cases;  as  against  a  family 
history  of  insanity  in  7,  of  epilepsy  in  6,  apd  a  parent  mentally 
defective  in  2  cases  of  100  normal  children. 

For  several  years  past  I  Jiave  been  gathering  details  from  hospital 
and  private  patients,  and  I  am  fully  satisfied  that  the  extent  of 
neuropathic  inheritance  is  quite  insignificant  in  the  mentally 
normal  as  compared  with  the  defective  population.  Instances  of 
a  solitary  ancestor  being  epileptic  or  insane  are  not  rare,  but  it  is 
decidedly  exceptional  to  find  definite  and  pronounced  neuropathic 
heredity,  such  as  occurs  in  the  families  upon  which  my  statistics  are 
based,  in  an  individual  of  normal  bodily  and  mental  development. 

2.  Alcoholism. 

The  factor  which  occurs  next  in  frequenc}^  is  alcoholism — a  pro- 
nounced family  history  of  which  was  present  in  no  less  than  46-5 
per  cent,  of  my  cases.  It  is  to  be  remarked,  however,  that  in  five- 
sixths  of  these  there  was  a  definite  neuropathic  predisposition  also, 

*  E.  Riidin,  "  Wege  und  Ziele  Familien  Forschung,"  etc.,  Zeitschrift  fiir 
die  gesammte  Neurol,  u.  Psychiatric,  November  18,  191 1. 
f  E.  Sayer,  Eugenics  Review,  July,  1913. 


The  Causal  Factors  of  Amentia  43 

whilst  in  most  of  the  remainder  there  was  a  history  of  other  morbid 
influences. 

It  is  necessary  to  point  out  that  alcohol  may  act  in  two  ways. 
I  have  already  adduced  facts  showing  that  it  may  undoubtedly 
so  impair  the  germ  plasm  as  to  cause  pathological  variation;  but 
it  may  also  have  a  direct  effect  upon  the  embryo  after  fertilization 
has  taken  place.  As  is  well  known,  the  ingestion  of  alcohol  is 
rapidly  followed  by  its  appearance  in  the  blood,  and  since  it  has 
been  conclusively  shown  by  numerous  experiments  that  alcohol 
has  a  most  baneful  effect  upon  growing  protoplasm,  it  follows  that 
the  systematic  abuse  of  alcohol  by  a  pregnant  woman  may  be 
attended  with  decidedly  injurious  consequences  to  the  offspring. 
In  dealing  with  alcoholism,  therefore — and  the  same  applies  to 
such  other  toxic  agencies  as  tuberculosis,  syphilis,  lead,  etc. — unless 
the  father  alone  has  been  affected  it  is  not  always  possible  to  say 
whether  the  effect  is  upon  the  germ  plasm  or  upon  the  growing 
•embryo,  probably  both,  hence  both  these  modes  of  action  will  be 
considered  in  this  place. 

The  following  statistics  may  be  quoted  as  showing  the  extent  to 
which  a  history  of  alcoholism  has  been  found  in  the  families  of 
aments  by  other  inquirers.  Beach  and  Shuttleworth  in  16-3  per 
cent,  of  cases,  Kerlin  (Philadelphia)  in  38  per  cent.,  Howe  (America) 
in  over  25  per  cent,  of  idiots  found  that  the  parents  were  habitual 
drunkards;  Looft  (Norway)  in  37  per  cent.,  and  Kind  (Hanover) 
in  11  per  cent.  Potts  found  that  41-6  per  cent,  of  mentally  defec- 
tive children  in  Birmingham  had  alcoholic  antecedents. 

The  great  discrepancy  existing  between  these  figures,  together 
with  the  fact  that  a  history  of  alcoholism  is  usually  accompanied 
by  a  definite  history  of  insanity,  epilepsy,  or  other  neuropathic 
condition,  suggests  that  its  action  is  more  often  contributory  than 
directly  causal.  It  is  also  necessary  to  point  out  that  alcoholism 
may  be,  and  often  is,  an  indication  of  existing  nervous  weakness, 
and  this  being  the  case  the  extent  to  which  it  is  found  may  be 
dependent  upon  the  facilities  with  which  alcohol  is  obtainable  in 
different  situations.  It  is  also  necessary  to  remember  that  "  alco- 
holism "  is  a  vague  term,  and  may  mean  very  different  things  with 
different  observers. 

I  think  there  is  now  conclusive  evidence  that  either  paternal  or 
maternal  alcoholism  may,  in  the  absence  of  any  other  factor, 
produce  mental  defect ;  but  in  my  experience  such  a  result  is  not 


44  Causation 

common  in  this  county,  and  its  chief  action  seems  to  me  to  lie 
either  in  giving  rise  to  that  initial  impairment  of  the  germ  plasm 
which  may  be  the  forerunner  of  amentia,  or  in  accentuating  a 
neuropathic  diathesis  which  already  exists. 

The  subject  is  a  very  large  one,  and  there  can  be  no  doubt  that 
many  exaggerated  statements  have  been  made  regarding  it  by 
biassed  persons.  At  the  same  time  it  is  one  of  such  importance 
that  it  is  necessar}^  to  refer  to  a  few  facts  in  confirmation  of  the 
above  statements. 

The  following  case,  which  came  under  my  own  observation,  is  an 
illustration  of  alcohol  being  the  direct  cause  of  amentia.  The 
father  was  a  hard-working,  industrious  man,  sound  in  body  and 
mind,  and  coming  of  a  healthy  and  long-lived  family;  he  married 
the  daughter  of  a  small  publican,  apparently  a  healthy  and  happy 
girl,  who  used  occasionally  to  serve  behind  the  bar.  Shortly  after 
marriage  this  girl  developed  an  insatiable  craving  for  drink ;  all  the 
money  she  could  obtain  by  any  pretence  whatever  went  in  procur- 
ing it.  Later  the  ornaments  and  then  the  furniture  of  the  house 
were  pawned  to  feed  her  desires;  ten  months  after  marriage  she 
gave  birth  to  a  child — a  hydrocephalic  idiot,  and  according  to  the 
husband,  she  had  scarcely  known  a  sober  moment  during  the  pre- 
ceding four  or  five  months.  Further  inquiry  showed  that  this 
woman's  father  was  also  a  heavy  drinker,  but  otherwise  there  was 
an  entire  absence  of  any  neuropathic  condition  in  the  family.  Of 
course  it  may  be  that  the  alcoholic  taste  of  the  mother  was  in  itself 
evidence  of  the  neuropathic  diathesis,  but  I  cannot  help  thinking 
that  the  child's  condition  was  more  largely  due  to  an  actual  poison- 
ing during  its  intra-uterine  existence,  and  this  view  seems  to  be 
supported  by  the  subsequent  history,  for  the  next  child  that  was 
bom,  after  an  interval  of  nearly  two  years,  was  perfectly  normal, 
and  is  now  a  bright  and  intelligent  boy  of  eight  years ;  by  this  time 
however,  the  mother  had  recovered,  and  had  Hved  a  perfectly  steady 
Hfe  during  the  whole  of  the  pregnancy.  It  may  be  mentioned  that 
Galton*  described  the  case  of  a  man,  who,  after  begetting  several 
normal  children,  became  a  drunkard  and  had  imbecile  offspring. 

Several  writers  have  described  cases  of  mental  defect  which  have 

been  due  to  one  or  both  parents  being  intoxicated  at  the  moment 

of  conception,  and  Langdon  Down,  Sabatier,  Ouatrefages,  Lucon, 

Morel,  Bourneville,  and  others  are  of  opinion  that  idiocy  is  a  com- 

*   Quoted  by  Sullivan  in  "  Alcoholism." 


The  Causal  Factors  of  Amentia  45 

mon  sequence  of  such  a  condition.  Thus  Sabatier*  mentions, 
amongst  many  similar  instances,  that  of  a  robust  and  inteUigent 
peasant  of  Auvergne  who,  following  the  custom  prevailing  in  many 
villages  of  his  district,  passed  the  first  three  weeks  of  his  married 
life  in  drinking  and  jollification,  being  in  a  state  of  moderate 
alcohohc  intoxication  all  the  time.  Nine  and  a  half  months  later 
his  wife  gave  birth  to  an  imbecile  girl,  who  was  unable  to  learn  to 
read  or  write.  Demeaux,  also  Dehaut  and  Voisin,  have  traced 
cases  of  epilepsy  to  alcoholic  intoxication  of  the  parents  at  the 
time  of  conception.  Grenier,  studying  1S8  idiot  and  imbecile 
children,  found  that  in  7  the  condition  was  due  to  drunkenness 
of  the  parents  during  the  first  few  days  of  married  life. 

On  the  other  hand,  it  is  stated  by  Dr.  Ireland|  that  in  some 
parts  of  Scotland  whole  villages  of  the  lower  classes  get  drunk  at 
New  Year  time,  and  that  the  same  is  also  the  case  with  the  herring 
fishermen  when  they  return  to  port;  but  it  has  never  been  noticed 
that  the  resulting  children  were  idiotic.  Personally  I  have  histories 
of  idiots  conceived  under  such  circumstances,  but  so  I  have  of 
normal  children,  and  on  the  whole  I  am  of  the  same  opinion  as 
Nacke,|  that  whilst  such  a  result  may  certainly  be  possible,  it  only 
occurs  with  extreme  rarity. 

With  regard  to  the  influence  of  alcohol  in  bringing  about  less 
pronounced  neuropathic  conditions,  there  is  the  clearest  evidence, 
to  some  of  which  reference  has  already  been  made.  Thus  Dr. 
Wiglesworth,§  after  many  years'  study  which  embraced  3,450  cases 
of  insanity,  says  there  is  "a  direct  poisoning  of  the  germ  plasm 
itself  by  the  alcohol  circulating  in  the  blood,  and  a  consequent  direct 
injury  to  the  cells  of  which  this  structure  is  composed,  and  which 
by  reason  of  the  injury  are  prevented  from  developing  into  a  stable 
organism.  If  the  alcoholic  poisoning  of  the  germ  cells  and  ovum 
has  reached  a  certain  degree  of  intensity,  imbecility,  or  even  pro- 
found idiocy,  may  be  expected  to  result;  while  if  of  a  less  degree, 
the  injury  may  manifest  itself  in  the  various  forms  of  adolescent 
insanity,  when  adult  life  is  developing,  or  has  been  attained  to." 
His  conclusion  is  that  alcoholism  in  the  progenitors  is  a  fruitful  cause 
of  idiocy,  mental  defect,  insanity,  and  other  nervous  diseases  in 
the  offspring. 

*  Quoted  by  W.  L.  Andriezen  in  "  The  Problem  of  Heredity." 

j  W.  W.  Ireland,  "  Mental  Affections  of  Children,"  1898. 

X  p.  Nacke,  "  Die  Zeugung  im  Rausche,"  Neurolog.  Centralbl.,  No.  2,  1908. 

§  Wiglesworth,  Journal  of  Mental  Science,  October,  1902. 


4^  Causation 

Dr.  W.  C.  Sullivan*  conducted  an  inquiry  regarding  the  children 
of  120  women  who  were  habitual  drinkers,  excluding  all  those  who 
had  a  phthisical,  syphilitic,  or  neuropathic  taint,  with  the  following 
results:  "335  (55-8  per  cent.)  died  in  infancy  or  were  stillborn. 
Several  of  the  survivors  were  mentally  defective,  and  as  many  as 
4'i  per  cent,  were  epUeptic.  (The  proportion  of  epileptics  in  the 
general  population  is  o-i  per  cent.)  Many  of  these  women  had 
female  relatives,  sisters  or  daughters,  of  sober  habits,  and  married 
to  sober  husbands;  on  comparing  the  death-rate  amongst  the 
children  of  the  sober  mothers  with  those  amongst  the  drunken 
mothers  of  the  same  stock,  the  former  was  found  to  be  23-9  per 
cent.,  the  latter  55-2  per  cent.,  or  nearly  two  and  a  half  times  as 
much.  It  was  further  observed  that  in  the  drunken  families  there 
was  a  progressive  rise  in  the  death-rate  from  the  earlier  to  the  later 
bom  children.  ...  In  one  observation  where  the  first  three  children 
were  healthy,  the  fourth  was  of  defective  intelligence,  the  fifth  was 
an  epileptic  idiot,  the  sixth  was  dead-bom,  and  finally  the  repro- 
ductive career  ended  with  an  abortion." 

Professor  G.  von  Bunge,f  as  the  result  of  an  extensive  inquiry, 
comes  to  the  conclusion  that  tuberculosis  and  nervous  and  mental 
diseases  are  far  more  prevalent  in  the  descendants  of  drunkards 
than  in  those  of  abstainers.  His  figures  show  that  there  is  a  direct 
relation  between  the  extent  to  which  these  diseases  occur  and  the 
degree  to  which  the  parent  has  been  addicted  to  alcohol. 

An  extensive  inquiry  conducted  under  the  auspices  of  Dr.  T. 
Crothers,!  of  Connecticut,  U.S.A.,  by  a  number  of  skilled  physicians 
and  speciahsts,  and  which  was  based  on  the  study  of  1,744  cases  of 
inebriety,  showed  that  the  injury  produced  by  the  alcoholism  of 
parents  not  only  affected  the  nervous  system  of  the  immediate 
progeny,  but  that  the  ill-effects  were  also  transmitted  through  them 
to  the  later  progeny  of  the  third  generation  either  as  a  neurosis 
or  a  cerebral  defect. 

Such  evidence§  might  be  multiplied  almost  ad  nauseam  ;  but  the 

*  W.  C.  Sullivan,  "  Alcoholism." 

t  G.  von  Bunge,  "  Les  Sources  de  Degenerescence,"  1910. 

X   Crothers,  Quarterly  Journal  of  Inebriety,  January,  1901. 

§  For  further  particulars  consult  Horsley  and  Sturge,  "Alcohol  and  the 
Human  Body,"  1907;  a  very  interesting  paper  on  "  The  Problem  of  Heredity," 
by  Dr.  \V.  L.  Andriezen,  Journal  of  Mental  Science,  January,  1905;  a  com- 
prehensive article  by  Dr.  W.  A.  Potts  on  "  The  Relation  of  Alcohol  to  Feeble- 
mindedness," with  discussion  thereon,  in  British  Journal  of  Inebriety,  January, 
1909;  and  Dr.  W.  C.  Sullivan's  valuable  work  on  "  Alcoholism,"  1906. 


The  Causal  Factors  of  Amentia  47 

above  is  sufficient  to  show  the  important  influence  exerted  by 
alcoholism  in  the  production  of  mental  defect. 

3.  Tuberculosis. 

I  believe  that  ancestral  tuberculosis  is  but  rarely  the  direct  and 
sole  cause  of  amentia;  but  my  observations  show  that,  like  alco- 
holism, it  has  an  important  indirect,  and  possibly  also  a  contribu- 
tory, influence.  This  indirect  effect  is  seen  in  its  potency  to  produce 
the  mflder  and  initial  forms  of  nervous  instability  in  the  offspring, 
such  as  migraine,  hysteria,  and  neurasthenia,  a  clinical  fact  which 
has  been  frequently  noticed. 

Dr.  T.  D.  Savill*  states  that  persons  suffering  from  neurasthenia 
are  often  the  children  of  alcoholic  and  tuberculous  parents,  but  that 
a  history  of  hereditary  insanity  is  not  common.  "  For  some  reason 
which  does  not  appear  on  the  surface,  I  find  among  my  cases  quite 
a  number  whose  family  history  shows  no  nervous  ailments,  but 
tuberculosis  on  one  or  both  sides." 

\\^ith  regard  to  persons  suffering  from  amentia,  I  found  a  pro- 
nounced tendency  to  tubercular  lesions  in  the  families  of  34  per 
cent,  of  cases  investigated.  Beach  and  Shuttleworth  found  this 
factor  in  close  on  30  per  cent.,  Langdon  Down  in  22*5  per  cent., 
and  Kerlin  in  56  per  cent,  of  cases.  Potts  found  that  tubercular 
antecedents  occurred  in  43-2  per  cent,  of  defective,  as  compared 
with  17  per  cent,  of  normal,  children.  It  is  to  be  noted,  however, 
that  a  history  of  antecedent  tuberculosis  rarely  occurs  alone;  in  four- 
fifths  of  my  own  cases  it  was  accompanied  by  a  definite  neuropathic 
inheritance,  whilst  in  the  remaining  fifth  other  conditions — usually 
alcoholism — were  also  present. 

There  can  be  no  doubt  that  the  death-rate  from  tuberculosis  is 
very  much  higher  (nearty  four  times  as  much)  in  the  case  of  aments 
than  it  is  in  the  non-defective  population.  This  applies  in  a  some- 
what less  degree  to  neuropaths  generally ;  but  whether  it  is  the  result 
of  special  predisposition  to  this  disease,  or  whether  it  is  simply  a 
consequence  of  their  general  want  of  resistance  and  feeble  vitality, 
I  do  not  know. 

4.  Syphilis. 

The  investigation  of  family  histories  would  lead  to  the  conclusion 
that  syphilis  was  not  a  frequent  cause  of  amentia.     Fletcher  Beach 

*  T.  D.  Savill,  "  Lectures  on  Neurasthenia,"  1908. 


48  Causation 

found  it  present  in  but  T-iy  per  cent,  of  the  2,400  pauper  aments 
he  examined  from  the  London  area.  LangdonDown  and  Shuttle- 
worth  found  it  in  about  2  per  cent.,  and  Potts  in  4  per  cent.,  of  cases ; 
whilst  in  my  own  series  only  2-5  per  cent,  of  the  patients  examined 
presented  undoubted  marks  of  this  disease.  But  the  history  in 
such  cases  is  notoriously  misleading;  further,  not  only  may  the 
characteristic  lesions  be  so  slight  as  easily  to  escape  detection,  but 
it  is  now  an  established  fact  that  they  may  be  absent  altogether, 
and  yet  the  individual  suffer  from  the  syphilitic  virus.  During  the 
past  few  years  I  have  seen  several  cases  of  amentia  of  the  ordinary 
simple  variety  in  which  the  closest  examination  failed  to  reveal  any 
syphilitic  lesions,  and  yet  there  was  not  only  a  well-marked  history 
of  paternal  and  maternal  infection,  but  both  elder  and  younger 
members  of  the  family  showed  typical  lesions. 

Under  these  circumstances  one  would  expect  that  the  Wasser- 
mann  reaction  would  supply  us  with  far  more  reliable  evidence  of 
the  presence  of  syphilis  than  would  an  investigation  of  the  family 
history  or  a  minute  inspection  of  the  patient,  and  this  has  now  been 
applied  to  a  very  considerable  number  of  patients.  Whether  it  is 
that  there  are  great  differences  in  the  clinical  material  used,  or 
variations  in  the  technique  of  applying  the  reaction,  or  real  differ- 
ences in  the  incidence  of  syphilis,  I  do  not  know;  but  it  is  certainly  a 
fact  that  the  results  of  different  workers  vary  in  the  most  marked 
manner.  Thus,  in  France,  Raviart*  and  others  obtained  a  positive 
reaction  in  30  per  cent,  of  cases.  In  Germany,  Kroberj  in  21  per 
cent.;  but  KellnerJ  and  others  in  only  37  per  cent.,  and  Thomsen§ 
and  others  in  only  1-5  per  cent.  In  America,  Attwoodll  in  15  per 
cent,  of  cases.  In  England,  Dean^  in  15-4  per  cent.,  Thomas**  in 
4-8  per  cent.,  and  Gordon tj  in  16-5  per  cent. 

The  most  recent  results  are  those  of  Dr.  Gordon,  ff  which  are  based 
upon  the  examination  of  400  patients  suffering  from  various  forms 
of  congenital  mental  deficiency  in  the  asylums  of  the  Metropolitan 
Asylums  Board.     Dr.  Gordon  has  analyzed  his  results  according  to 

*  Raviart  and  others,  Revue  de  MSdecine,  Paris,  vol.  xxviii.,  No.  9,  1909. 
t   Krober,  Medicin  Klinik,  Vienna,  Band  vii.,  191 1. 

X  Kellner  and  others,  Deutsch.  Med.  Wochenschrift,  BerUn,  vol.  xxxv.,  Oct., 
1909. 

§  Thomsen  and  others,  Berlin.  Klin.  Woch.,  Band  xlviii.,  191 1. 

II  Attwood,  Journal  of  American  Medical  Association,  Chicago,  vol.  Iv.,  1911. 

•[f  Dean,  Lancet,  July  23,  1910. 

**  Thomas,  Report  of  Lunacy  Commissioners,  191 3. 

\\  Gordon,  Lancet,  September  20,  1913. 


The  Causal  Factors  of  Amentia  49 

various  clinical  conditions  present,  from  which  it  appears  that, 
whilst  the  reaction  was  positive  in  13-3  per  cent,  of  non-epileptic 
patients,  it  occurred  in  21-5  per  cent,  of  those  who  were  subject  to 
epilepsy.  Similarly,  it  occurred  in  ii-2  per  cent,  of  non-plegic  cases, 
but  in  31-4  per  cent,  of  those  suffering  from  some  form  of  paralysis. 
A  reaction  was  obtained  in  11-9  per  cent,  of  patients  of  the  simple 
variety  of  amentia  without  paralysis,  but  in  3i'8  per  cent,  of  this 
variety  complicated  by  paralysis.  And  it  seems  probable  that,  if 
a  positive  reaction  be  accepted  as  conclusive  evidence  of  syphilis, 
the  incidence  of  this  is  even  greater  than  that  revealed,  by  these 
figures,  for  there  were  several  patients  in  whom  the  reaction  was 
negative  who  yet  presented  definite  lesions  which  have  long  been 
recognized  as  syphilitic. 

As  to  the  mode  of  action  of  this  agent,  I  think  there  is  no  doubt 
that  syphilis  is  capable  of  producing  an  impairment'  of  the  germ 
cell,  in  consequence  of  which  a  condition  of  primary  amentia 
results,  which  is  probably  indistinguishable  from  primary  amentia 
in  general,  or  which  may  possess  hitherto  unrecognized  particular 
features.  On  the  other  hand,  the  poison  may  act  upon  the  embryo 
after  fertilization;  the  child,  in  fact,  is  directly  infected  by  the 
mother,  and  suffers  from  "  congenital  "  (erroneously  termed  "  in- 
herited ")  syphilis,  and  it  is  in  these  cases  that  Wassermann's  reac- 
tion would  be  more  likely  to  yield  a  positive  result.  The  fact  that, 
in  many  cases  of  infection,  the  neuronic  arrest  and  degeneration 
present  histological  features  different  from  the  ordinary  syphilitic 
lesions  led  Fournier*  and  others  to  conclude  that,  although  they  were 
a  consequence  of  syphilis,  they  were  not  actually  syphilitic,  and  to 
designate  them  "  parasyphilitic  ";  but  the  recent  work  of  Mcintosh 
and  Fildest  affords  strong  reason  for  thinking  that  such  conditions 
do  not  differ  in  any  way  etiologically  from  other  syphilitic  diseases 
-of  the  central  nervous  system. 

There  is  no  doubt  that  by  either  of  these  modes  syphilis,  acting 
alone,  can  produce  mental  defect,  and  I  have  seen  several  cases  in 
which  the  most  searching  inquiry  failed  to  reveal  evidence  of  neuro- 
pathic predisposition  or  any  other  adverse  factor  whatever.  At 
the  same  time,  I  am  inclined  to  think  that  the  proportion  of  cases 
so  arising  is  relatively  small,  and  in  the  majority  of  patients  in 

*  Fournier,  "  Les  Afiections  Parasyphilitiques,"  1894. 

t  Mcintosh  and  Fildes,  "  The  Pathology  of  the  Condition  known  as 
'  Parasyphihs,'  "  Lancet,  September  27,  1913. 

4 


50  Causation 

whom  syphilis  is  present  other  factors  will  be  found  in  addition, 
generally  a  neuropathic  inheritance.  It  is  necessary  to  remember 
that  a  child  may  suffer  from  congenital  syphilis,  and  yet  show  no 
mental  impairment;  at  the  same  time,  a  considerable  number  of 
such  individuals  do  often  manifest  peculiarities  of  mind  at  a  later 
age.  I  am  disposed  to  think  that  the  result  is  largely  influenced 
by  the  presence  or  absence  of  neuropathic  taint.  The  syphilitic 
poison  seems  to  have  a  predilection  for  finding  out  the  weak  spot, 
and  if  a  predisposition  to  nervous  weakness  exists,  the  chance  of 
the  child  of  syphilitic  parents  being  mentally  deficient  seems  to  me 
to  be  very  considerable;  in  the  absence  of  such,  it  may  probably 
escape. 

5.  Consanguinity. 

It  is  the  general  opinion  that  the  intermarriage  of  blood  relations 
is  fraught  with  considerable  evil  effects,  both  mental  and  physical, 
to  the  offspring.  That  this  is  the  case  in  certain  of  the  domesti- 
cated animals  there  seems  to  be  no  doubt,  and  practically  alL 
breeders  of  experience  are  unanimous  that  injury  is  almost  certain 
to  result  from  repeated  "  in-breeding."  The  effects  upon  the  off- 
spring are — The  nervous  system  is  rendered  more  unstable,  and 
therefore  more  excitable;  any  existing  constitutional  defects  are 
intensified ;  the  size  tends  to  decrease ;  and  there  is  produced  a  pre- 
disposition to  disease  and  an  impairment  of  the  reproductive  func- 
tions. In  other  words,  the  result  is  a  deterioration,  and  of  exactly 
the  same  nature  as  that  deterioration  which  takes  place  in  the 
human  being,  the  final  expression  of  which  is — idiocy.  If,  therefore, 
we  can  argue  from  the  lower  animals  to  man  in  this  respect,  con- 
sanguinity is  undoubted^  harmful. 

In  the  case  of  man,  in-breeding  to  this  extent  is  practically  un- 
known; but  instances  are  not  wanting  in  which  intemiarriage  has 
taken  place  for  many  generations  without  the  slightest  untoward 
result.  Thus,  Voisin,*  who  investigated  the  offspring  of  fort^'-six 
consanguineous  marriages  in  the  commune  of  Batz,  where  inter- 
marrying had  been  the  rule  for  several  generations,  says  that  "  in- 
sanity, idiocy,  and  deaf-mutism  are  unknown  ";  and  the  same 
author  could  not  find  consanguinity  the  cause  of  mental  deficiency 
in  a  single  case  at  the  Bicetre  and  Salpetriere.     Huthf  also  is  of 

*   Jules  Voisin,  "  L'Idiotie,"  Paris,  1893. 

t   Alfred  Huth,  "  Marriage  of  Near  Kin,"  London,  1875. 


The  Causal  Factors  of  Amentia  51 

opinion  that  this  practice  is  not  attended  with  harm  if  the  family  is 
health}^  and  instances  the  inhabitants  of  Pitcairn  and  Iceland  in 
support  of  his  statement.  George  Darwin*  arrived  at  a  similar  con- 
clusion. 

The  Jews  and  Quakers  are  well-known  instances  of  modified  inter- 
marrying. With  regard  to  the  Jews,  there  can  be  no  doubt  that 
whilst  many  of  them  evince  a  very  high  degree  of  intellectual  and 
artistic  ability,  yet  as  a  race  they  are  exceedingly  neurotic  and 
prone  to  insanity. 

Still,  it  must  not  be  too  readily  assumed  that  consanguinity  is 
necessarily  responsible  for  all  this.  When  one  recalls  the  wretched 
conditions  under  which  the  Jews  have  been  compelled  to  live  for 
at  least  the  past  2,000  years,  from  which,  indeed,  even  now  they 
are  in  many  places  not  free,  and  when  one  thinks  of  the  constant 
harrying  to  which  they  have  all  this  time  been  subjected,  it  is  not 
improbable  that  other  factors  than  consanguinity  may  have  left 
their  mark  upon  the  nervous  system  of  the  Jew. 

As  to  the  Quakers,  I  have  been  unable  to  obtain  any  actual 
figures,  but  I  have  been  assured  by  several  people  who  have  an  inti- 
mate knowledge  of  them,  that  the  pure  Quakers  are  rapidly  becoming 
extinct,  and  that  insanity  is  very  rife  amongst  them. 

The  crux  of  the  whole  question  is  the  presence  of  morbid  inherit- 
ance, not  of  consanguinity,  and  I  believe  the  result  to  be  entirely 
dependent  upon  the  presence  or  absence  of  a  constitutional  taint. 
Should  such  be  present,  it  will,  of  course,  tend  to  be  accentuated, 
and  the  effect  upon  the  offspring  may  be  disastrous.  In  its  absence, 
however,  I  doubt  whether  any  untoward  result  is  likely  to  foUow, 
and  I  certainly  do  not  think  that  amentia  will  arise.  As  a  matter 
of  fact,  a  considerable  amount  of  intermarrying  still  takes  place  in 
certain  localities  of  our  own  country,  such,  for  instance,  as  inacces- 
sible islands  in  the  north  of  Scotland  and  out-of-the-way  rural 
districts;  but  I  know  of  no  statistics  showing  that  in  these  cases  it 
has  been  responsible  per  se  for  the  occurrence  of  mental  deficiency. 
At  the  same  time  there  are  many  biological  objections  to  the  prac- 
tice, and  it  is  not  one  to  be  advocated. 

In  my  opinion,  therefore,  the  statement  that  consanguinit\-  is, 
in  itself,  an  important  cause  of  amentia  is  one  not  supported  by 
facts.  In  my  own  series  of  cases  I  found  that  onty  5  per  cent,  of 
defectives  were  the  offspring  of  blood  relations,  and  in  all  of  these 

*  G.  Darwin,  Journal  of  the  Statistical  Society,  June,  1875. 


52  Causation 

a  pronounced  neuropathic  heredity  was  present.  A  similarly  small 
percentage  is  revealed  by  several  other  inquirers.  Thus,  Beach 
and  Shuttleworth  found  consanguinity  in  4-2  per  cent.,  Down  in 
7  per  cent.,  Kerlin  in  7  per  cent.,  and,  in  fact,  the  result  of  careful 
research  is  decidedly  to  discount  this  factor  as  a  cause  of  amentia. 
Langdon  Down,  indeed,  says:  "  I  am  by  no  means  sure  that  by  a 
judicious  selection  of  cousins  the  race  might  not  be  improved." 

Dr.  Gillet,*  of  Paris,  came  to  the  conclusion  that  consanguinity 
played  a  most  important  part  in  the  production  of  idiocy,  and  at 
first  sight  his  statistics  seem  fuUy  to  bear  out  his  contention;  but 
on  a  closer  examination  it  is  evident  that  he  has  completely  ignored 
the  question  of  the  mental  or  physical  condition  of  the  ancestors, 
and  simply  taken  note  of  the  presence  or  absence  of  blood  relation- 
ship. 

6.  Age  of  Parents. 

There  are  reasons  for  thinking  that  the  age  of  the  parents  at 
conception  is  not  without  influence  upon  the  vitaUty  of  the  child. 
Thus  Korosi,t  as  a  result  of  the  investigation  of  24,000  unselected 
individuals,  came  to  the  conclusion  that  the  children  of  fathers 
below  twenty  and  above  forty  years  are  weaker  than  when  the 
fathers  are  between  these  ages;  also  that  the  children  of  mothers 
over  forty  years  of  age  are  weaker  than  those  born  when  the  mother 
is  below  this  age.  Dr.  Antonio  Marro,|  Director  of  the  Lunatic 
Asylum  of  Turin,  after  a  very  extensive  series  of  observations,  came 
to  the  same  conclusion,  and  considers  that  both  mental  and  physical 
stigmata  of  degeneracy  are  commoner  in  children  bom  of  parents 
under  the  age  of  twenty-six  and  over  that  of  forty  than  in  those 
born  between  these  ages.  Matthews  Duncan  §  was  of  opinion  that 
premature  and  late  marriages  w^ere  influential  in  the  production  of 
idiocy,  and  Langdon  Downil  found  that  in  23  per  cent,  of  idiots 
there  was  a  disparity  of  more  than  ten  years  in  the  ages  of  the 
parents.  Amongst  my  own  patients  a  similar  disparity  existed  in 
4  per  cent,  of  cases,  in  all  of  them  the  father  being  the  elder.  In 
one  case  the  difference  in  age  was  as  much  as  thirty-two  years.     In 

*   Gillet,  "  These  de  Paris,"  1900. 

f  Korosi,  Transactions  of  the  International  Congress  of  Hygiene,  London, 
1S91,  vol.  X. 

+  A.  JMarro,  "  Influence  of  Age  of  Parents  on  Offspring,"  "  Problems  in 
Eugenics,"  1912. 

§  Matthews  Duncan,  Lancet,  January  and  March,  1SS3. 

II  Langdon  Down,  "  Notes  of  One  Thousand  Cases  of  Idiocy." 


The   Causal   Factors  of  Amentia  53 

all  these  families,  however,  a  well-marked  neuropathic  diathesis  was 
present,  and  as  I  have  knowledge  of  several  cases  in  which  a  similar 
difference  existed  without  morbid  heredity,  where  the  offspring  is 
perfectly  healthy,  I  am  of  opinion  that  the  influence  of  such  a  con- 
dition is,  in  itself,  really  infinitesimal. 

Factors  acting  directly  upon  the  Offspring. 

These  factors  may  most  conveniently  be  referred  to  under  the 
three  headings — Before,  During,  and  After  Birth. 

Those  acting  before  birth  are  most  referable  to  some  unhealthy 
mental  or  physical  condition  of  the  mother  during  pregnancy, 
although  an  actual  injury  to  the  foetus  may  also  occur  during  this 
time.  During  birth  they  chiefly  relate  to  the  various  abnormalities 
attending  labour,  and  in  this  place  reference  will  also  be  made  to 
primogeniture  and  premature  birth.  After  birth  the  factors  are 
either  traumatic,  toxic,  convulsive,  or  some  disturbance  profoundly 
influencing  nutrition. 

There  is  no  doubt  that  a  history  of  one  or  other  of  these  factors 
can  be  elicited  in  a  considerable  number  of  cases  of  amentia.  In 
my  own  series  they  were  present  in  no  less  than  65  per  cent.;  but, 
as  will  be  shown,  the  proportion  of  cases  in  which  they  are  the  sole 
cause  is  relatively  small,  and  in  the  majority  of  instances  their  effect 
is  contributory  only. 

I.  Before  Birth. 

I.  Abnormal  Condition  of  the  Mother  during  Pregnancy. — The 
abnormal  condition  of  the  mother  may  be  either  physical  or  mental. 
The  former  may  be  due  to  the  presence  of  actual  disease  or  to  a 
state  of  general  enfeeblement  independent  of  any  specific  illness. 
The  latter  embraces  worry,  sudden  shock  or  fright,  and  the  much- 
debated  question  of  maternal  impressions. 

With  regard  to  the  mother's  physical  condition,  my  inquiries  show 
this  to  have  been  unsatisfactor}^  in  about  one-fifth  of  the  cases 
excimined;  but  since  in  the  great  majority  there  was  also  a  marked 
history  of  neuropathic  predisposition,  it  is  clear  that  this  factor  alone 
cannot  be  regarded  as  a  very  prevalent  direct  cause.  At  the  same 
time  I  am  disposed  to  think  that  under  certain  circumstances  its 
contributory  or  determining  action  may  be  very  considerable.  It 
is  to  be  remembered  that  even  where  there  is  no  innate  germinal 
weakness,  the  development  of  the  embryo  is  still  largely  dependent 


54  Causation 

upon  the  quantity  and  quality  of  nutriment  it  receives  through  the 
placental  circulation ;  hence,  if  the  mother  is  suffering  from  serious 
disease  or  nutritional  defect,  the  growth  of  the  offspring  is  hardly 
likely  to  be  up  to  the  normal  standard.  Where  some  degree  of  ger- 
minal impairment  is  present,  however,  the  condition  of  the  mother 
may  suffice  to  turn  the  scale  from  a  degree  of  development  com- 
patible with  the  needs  of  everyday  life  to  one  of  mental  deficiency. 
As  I  have  already  remarked,  it  is  quite  likely  that  contributory  or 
determining  factors  of  the  kind  we  are  now  considering  explain  the 
occurrence  of  sporadic  cases  of  idiocy  in  a  family  of  which  the 
brothers  and  sisters  show  no  marked  mental  deterioration. 

In  a  small  proportion  of  cases  it  seems  likely  that  the  presence 
of  serious  disease  of  the  mother  during  gestation  may  have  such  an 
inimical  effect  upon  the  development  of  the  child  as  actually  to 
produce  mental  defect.  Thus,  Sir  James  Crichton-Browne,  in  his 
evidence  before  the  Royal  Commission,  mentions  the  case  of  an 
idiot  whose  mother,  during  pregnancy,  suffered  from  an  attack  of 
Asiatic  cholera;  her  other  children,  born  before  and  after  the  idiot, 
being  perfectly  healthy.  Dr.  Potts  mentions  a  case  in  which 
amentia  was  probably  caused  by  a  severe  attack  of  typhus  shortly 
before  marriage,  and  another  in  which  the  mental  abnormality  was 
due  to  the  mother  having  typhoid  fever  at  the  fifth  month.  Dr. 
Heller*  describes  three  aments  whose  mothers  suffered  from  malaria 
during  gestation. 

As  further  illustrating  this  point,  allusion  may  be  made  to  the 
recent  researches  of  Dr.  Catola,t  of  Florence.  He  examined  the 
spinal  cords  of  infants  dying  at  birth  whose  mothers  had  been  suffer- 
ing from  chronic  disease,  and  found  definite  indications  of  defective 
development,  chiefly  in  the  form  of  imperfect  myelination  of  certain 
-of  the  nerve  tracts.  He  concludes  that  "  different  morbid  condi- 
tions in  the  maternal  parent  msLy  be  associated  with  defects  of  de- 
velopment and  slight  lesions  in  the  central  nervous  system  of  the 
children,  such  as  may,  in  the  case  of  the  latter  surviving,  play  a 
certain  role  in  the  mechanism  of  morbid  predisposition." 

Reference  may  also  be  made  to  the  researches  of  Fere  already 
quoted,  and  to  those  of  DaresteJ  and  Windle.§     Dareste  produced 

*  Heller,  "  Grundriss  der  Heilpadagogik,"  1904. 

I   Catola,  Revue  de  MSdecine,  September,  1910. 

+   Dareste,  "  Recherches  sur  la  Production  Artificielle  des  Monstrosities," 

Paris,  1877. 

§  Windle,  Proceedings  of  the  Birmingham  Philosophical  Society,  vii.,  1S90. 


The  Causal  Factors  of  Amentia  55 

various  monstrosities  by  treating  fowls'  eggs  in  different  ways; 
Windle  corroborated  this,  and  also  obtained  monstrosities  by  sub- 
jecting eggs  to  such  agencies  as  electricity  and  magnetism. 

I  have  already  remarked  that  the  presence  of  maternal  alcoholism, 
tuberculosis,  syphilis,  and  plumbism  constitute  an  adverse  environ- 
ment which  may  have  an  important  contributory,  or  occasionally 
even  direct,  influence  in  the  production  of  mental  defect.  Rennert* 
states  that  many  of  the  women  employed  in  the  pottery  factories 
of  Germany  suffer  from  a  form  of  plumbism,  which  gives  rise  to 
frequent  abortions,  deaf-mutes,  and  macrocephalics.  The  same  is 
probably  true  also  of  ecbolics.  It  is  stated  that  the  use  of  these 
drugs  in  America  is  responsible  for  a  considerable  number  of  cases 
of  feeble-mindedness,  and  Sir  James  Crichton-Browne  gives  it  as 
his  opinion  that  where  abortion  "  is  instrumentally  attempted 
without  success,  injury  may  be  done  to  the  head  of  the  foetus,  and 
where  drugs  are  used,  these  may  disastrously  interfere  with  its 
nutrition  and  growth." 

It  must,  however,  be  emphasized  that  cases  of  amentia  directly 
resulting  from  any  of  these  causes  are  relatively  rare,  and  that  in 
the  large  majority  of  defectives  such  physical  conditions  of  the 
mother  have  a  contributory  influence  only. 

Illegitimacy  has  been  credited  with  the  causation  of  amentia. 
It  is  no  doubt  responsible  for  a  very  high  proportion  of  infantile 
deaths,  t  and  statistics  show  that  this  is  on  account  of  the  adverse 
environment  in  such  cases,  but  I  do  not  think  it  is  ever  in  itself  a 
direct  cause  of  mental  defect. 

The  mental  state  of  the  mother  during  gestation  would  appear  to  be 
of  considerably  less  importance,  as  was  shown  by  an  inquiry  I  made 
into  the  condition  of  children  born  whilst,  or  shortly  after,  the 
mother  was  insane.  This  is  by  no  means  an  uncommon  event ;  in 
fact,  a  certain  number  of  children  are  born  every  year  within  lunatic 
asylums,  and  I  have  traced  the  subsequent  history  of  thirty-eight 
of  these  up  to  periods  at  which  any  mental  abnormality  would  have 
been  evident.  In  fourteen  of  these  women  the  insanity  was  of  a 
temporary  nature,  due  solely  to  nervous  breakdown  at  a  trying 
period,  and  hereditary  predisposition  was  absent.  Out  of  the 
fourteen  children,  ten  were  alive  and  well  in  body  and  mind  at  ages 
varying  from  three  to  fifteen  years,  whilst  four  were  dead.     On  the 

*   Rennert,  American  Journal  of  Obstetrics,  October,  1882. 

t    See  Dr.  Lankester's  report,  quoted  in  Newsholme's  "  Vital  Statistics." 


56  Causation 

other  hand,  in  twenty-four  women,  the  attack  of  insanity  was  ac- 
companied by  a  pronounced  neuropathic  inheritance.  Out  of  these 
children  only  three  were  alive  and  well,  whilst  twenty-one  had  sue- 
cumbed,  all,  with  one  exception,  a  few  months  after  birth.  Owing 
to  the  great  dif&culty  of  following  up  such  cases,  these  figures  are 
necessarily  small;  but  I  cannot  do  other  than  regard  them  as  evi- 
dence of  the  slight  effect  of  the  mental  state  during  gestation,  and 
of  the  important  influence  of  morbid  heredity. 

With  regard  to  the  much-debated  question  of  maternal  impres- 
sions, without  entering  into  this  subject  in  any  detail,  it  can  be  said 
that  both  these  and  the  sudden  frights  and  shocks  which  are  often 
alleged  to  be  the  cause  of  the  patients'  condition  really  have  very 
little  influence.  So  far  I  have  been  unable  to  discover  a  single  case 
of  this  nature  in  which  hereditary  influences  (commonly  insanity) 
were  not  forthcoming  upon  a  careful  inquiry  into  the  antecedents, 
so  that,  whilst  being  unable  to  deny  the  possibility  of  amentia 
resulting  from  such  conditions,  it  can  certainly  be  positively  affirmed 
that  such  instances  are  exceedingly  rare  (see  footnote  on  p.  69). 

An  instance  which  is  sometimes  quoted  in  support  of  the  influence 
of  maternal  impressions  is  the  siege  of  Paris.  Legrand  du  Saulle 
says:  "  Out  of  92  children  bom  in  Paris  during  the  great  siege  of 
1870-71,  64  had  mental  and  physical  anomalies,  and  the  remaining 
28  were  weakly;  21  were  imbecile  or  idiotic,  and  8  showed  moral  or 
emotionalinsanity."  But  may  it  not  be  that  these  effects  were  the 
result  of  the  physical  condition  of  the  mothers  during  this  dreadful 
time — of  the  environment  rather  than  of  any  mental  impression  ? 

2.  Injuries  to  the  Fcetus. — In  a  few  cases  amentia  is  attributed  to 
an  injury  received  during  intra-uterine  existence,  but  as  these  in 
no  way  differ  from  those  in  which  injury  is  inflicted  after  birth,  it 
will  be  better  to  consider  them  with  the  latter  group. 

2.  During  Birth. 

I.  Abnormal  Labour. — It  is  generally  considered  that  this  is  a 
very  important  and  frequent  cause  of  mental  deficiency.  Beach  and 
Shuttleworth  attribute  no  less  than  17-5  per  cent,  of  their  cases  to 
such  cause,  of  which  14-2  per  cent,  were  due  to  protracted  labour 
causing  pressure,  and  3-3  per  cent,  to  instrumental  delivery.  It  is 
to  be  remembered,  however,  that  these  statistics  were  confined  to 
institution  cases,  and  I  believe  that  such  are  hardly  representative 
of  amentia  in  general. 


The  Causal  Factors  of  Amentia  ^y 

Where  difficulty  in  parturition  causes  mental  defect,  it  is  because 
a  gross  lesion  of  the  brain  has  been  produced;  such  cases  are  gener- 
ally of  a  severe  degree,  and  consequently  tend  to  gravitate  to  the 
special  institutions.  In  corroboration  of  this  I  found  that  a  history 
of  these  factors  was  much  more  common  among  the  severer  grades 
at  Darenth  Asylum  than  amongst  the  patients  in  the  London  County 
asylums ;  but  even  in  those  at  Darenth  careful  inquiries  elicited  that 
in  the  majority  pronounced  morbid  heredity  was  also  present. 
Out  of  i8  per  cent,  of  cases  in  which  I  obtained  a  history  of  abnormal 
labour,  precipitate  labour  occurred  in  2  per  cent.,  protracted  labour 
with  asphyxia  in  14  per  cent.,  and  instrumental  delivery  in  2  per 
cent. ;  but  in  only  one-ninth  of  these  was  there  no  neuropathic  pre- 
disposition. All  of  these  latter  were  cases  of  asphyxia  neonatorum, 
and  as  they  are  confirmed  epileptics,  it  is  probably  largely  owing  to 
the  convulsions  that  the  mental  arrest  is  due. 

I  am  therefore  of  opinion  that  the  importance  of  abnormalities 
of  labour  as  a  cause  of  amentia  has  been  much  overrated,  and  that 
the  total  number  of  cases  which  are  the  immediate  consequence  of 
these  conditions  is  relatively  very  small,  being  probably  not  more 
than  I  or  2  per  cent,  of  all  aments.  It  is  true  that  the  parents  of  the 
patients  are  generally  quite  satisfied  with  this  explanation ;  they  find 
it  much  more  comforting  to  believe  that  the  unfortunate  child  is  the 
victim  of  some  extraneous  factor  than  the  product  of  hereditary 
taint;  but  I  am  convinced  that,  if  careful  inquiries  are  made  into  the 
family  histories  of  these  cases,  pronounced  hereditary  tendency  will 
be  found  in  a  very  large  proportion.  On  the  other  hand,  there  can 
be  no  doubt  that  where  such  morbid  heredity  exists,  any  difficulty 
during  labour — and  especially  if  attended  with  asphyxia — will  have 
an  important  contributory  effect ;  and  it  is  certainly  responsible  for 
many  of  the  gross  brain  lesions,  with  their  resulting  paralyses  and 
convulsions,  which  are  so  common  in  the  more  severe  grades.  It 
is  to  be  remarked  that  abnormal  presentations  and  anomalies  of 
labour  are  probably  of  much  greater  frequency  in  psychopathic 
than  in  mentally  sound  women,  as  also  with  defective  than  with 
normal  children. 

Little,*  in  an  important  paper  published  in  the  year  1862,  was 

the  first  in  this  country  to  draw  attention  to  mental  and  physical 

defects  resulting  from  abnormalities  of  labour.     He  collected  a 

series  of  63  cases  presenting  various  defects  of  this  kind,  the  most 

*  Little,  Transactions  of  the  London  Obstetrical  Society,  1862. 


58  Causation 

common  cause  being  asphyxia  due  to  protracted  deliver}^"  but  he 
himself  says:  "  It  is  obvious  that  the  great  majority  of  stillborn 
infants  whose  lives  are  saved  by  the  attendant  accoucheur  recover 
unharmed  from  that  condition  " — a  statement  which  has  since  been 
fully  endorsed  by  many  eminent  obstetricians,  and  which  is  con- 
firmed by  everyday  experience.  It  is  indisputable  that  in  a  certain 
small  percentage  of  cases  in  which  asphyxia  or  haemorrhage  occurs 
some  degree  of  paralysis  results — indeed,  this  condition  is  known  as 
"  Little's  disease  " — also  that  of  the  causes  so  affected  a  small  number 
may  show  mental  impairment.  Out  of  the  63  cases  of  lesions  col- 
lected by  Little,  however,  there  were  only  11  in  which  the  intellect 
suffered,  2  of  these  being  actually  idiotic,  and  the  remaining  9 
suffering  from  various  degrees  of  feeble-mindedness.  In  all  his 
cases  the  patients  were  seen  at  an  age  at  which  mental  impairment 
would  have  been  noticed  had  it  existed,  and  in  some  of  those  who 
were  physically  defective  the  mental  capacity  is  described  as  being 
beyond  the  average.  Unfortunately,  Little  did  not  inquire  into 
the  family  history  of  his  cases,  but  his  paper  affords  no  evidence  that 
amentia  is  at  all  a  common  result  of  abnormality  of  labour.  In  this 
connexion  it  may  be  remarked  that  it  is  recorded  of  Samuel  Johnson 
that  "  he  was  bom  almost  dead,  and  did  not  cry  for  some  time." 

With  regard  to  instrumental  delivery,  we  have  only  to  consider 
the  number  of  children  who  are  dehvered  by  forceps  every  day, 
and  the  fact  that  the  head  of  the  child  is  even  normally  subjected  to 
great  pressure  in  the  parturient  canal,  to  arrive  at  the  conclusion 
that  the  proper  use  of  the  forceps  can  play  no  practical  part  in  the 
production  of  amentia.  It  may  further  be  remarked  that  artificial 
compression  of  the  child's  head  after  birth  has  been  long  practised 
by  several  races  of  people,  and  is  even  now  still  in  use  in  the  Toulouse 
district  of  France,  without  any  apparent  evil  effects,  and  certainly 
without  producing  idiocy.  Dr.  Delisle*  says  that,  although  in 
France  the  practice  is  slowly  dying  out,  it  still  persists  to  a  sur- 
prising extent.  He  finds,  however,  that  it  shows  no  tendency  to 
become  hereditarily  impressed  upon  the  race,  nor  is  there  any  suffi- 
cient evidence  to  support  the  belief  that  it  causes  either  any  arrest 
of  physical  or  mental  development,  or  any  unusual  tendency  to 
insanity.     Lastly,  Spiegelbergj  says  that  "the  indentations  and 

*  Delisle,  "  Artificial  Deformity  of  the  Skull,"  Bull.  Soc.  d'Anth.  de  Paris, 
1902,  fasc.  2. 

t   Spiegelberg,  "  Textbook  of  Midwifery." 


The  Causal  Factors  of  Amentia  59 

depressions  which  result  in  the  cranial  bones  from  pressure  have  a 
comparatively  unimportant  influence  on  the  children." 

2.  Primogeniture. — It  is  said  that  iirst-born  children  are  more 
liable  to  be  mentally  defective  than  are  those  born  subsequently, 
and  this  is  attributed  partly  to  a  supposed  increased  mental  in- 
stability of  the  mother  during  a  first  pregnancy,  partly  to  the  un- 
doubted fact  that  labour  is  more  protracted  in  primiparae,  and 
partly  to  the  earlier  age  of  the  parents.  But  it  has  already  been 
seen  that  neither  the  mother's  mental  state  nor  protracted  labour 
really  have  very  much  influence  upon  the  intellectual  status  of  the 
child  in  the  absence  of  neuropathic  predisposition,  so  that  any  ill- 
effect  resulting  from  primogeniture  is  probably  attributable  to  the 
age  of  the  parents.  It  has  been  shown  by  Professor  Pearson,  also 
by  Dr.  Soren  Hansen,  that  there  is  a  greater  incidence  of  tubercu- 
losis in  first-born  than  in  later-born  children.  Mr.  David  Heron 
has  shown  that  this  is  also  the  case  with  insanity,  Dr.  Goring  with 
regard  to  criminal  tendencies,  and  Dr.  Crzillitzer  with  regard  to 
myopia.  Mdlle.  Robinovitch  also  brings  forward  some  evidence 
showing  that  distinguished  men  are  more  frequently  the  last-born 
members  of  the  family.  On  the  whole,  therefore,  it  certainly 
appears  possible  that  first-born  children  suffer  from  a  mental  and 
physical  inferiority  in  comparison  with  the  later  members  of  the 
family,  and  this  may  be  a  factor  in  determining  amentia,  where  a 
neuropathic  predisposition  exists.  But  that  primogeniture,  per  se, 
is  ever  the  cause  of  amentia,  I  do  not  believe,  and,  as  a  matter  of 
fact,  the  statement  that  an  undue  proportion  of  idiots  are  first - 
bom  children  is  by  no  means  proved,  and  can  only  be  settled  by 
a  very  extensive  series  of  statistics.  Certainly  my  own  experi- 
ence is  to  the  effect  that  it  is  more  common  for  the  later-born, 
and  not  the  first-born,  to  be  affected.  In  those  families  in  which 
there  is  a  pronounced  tendency  to  mental  and  physical  degeneracy, 
the  effects  usually  appear  to  be  more  and  more  marked  upon  each 
successive  child,  and  often  enough  the  idiot  is  actually  the  last  born. 
I  have  notes  of  not  a  few  families  in  which  the  first  one  or  two  chil- 
dren presented  no  great  departure  from  the  normal;  these  were  fol- 
lowed by  one  or  two  others  who  succumbed  to  ordinary  children's 
ailments,  from  which  healthy  children  would  probably  have  re- 
covered; then  came  the  idiot,  in  some  cases  to  be  succeeded  by  a 
number  of  stillbirths.  It  may  be  noted  that  this  sequence  is  the 
direct  opposite  to  that  which  occurs  in  syphilitic  infection. 


6o  Causation 

3.  Premature  Birth. — ^Where  hereditary  predisposition  exists,  it 
is  probable  that  the  child  who  is  prematurely  born  will  have  less 
chance  of  attaining  complete  mental  development  than  will  the  one 
who  goes  to  full  term ;  but  in  the  absence  of  other  factors  I  do  not 
believe  that  premature  birth  has  any  effect  upon  the  resulting 
mental  condition. 

3.  After  Birth. 

The  factors  acting  after  birth  which  are  capable  of  producing,  or 
assisting  in  the  production  of,  amentia  may  be  considered  under 
the  following  headings:  (i)  Traumatic;  (2)  toxic;  (3)  convulsive; 
(4)  nutritional. 

It  may  be  said  at  the  outset  that,  although  most  of  these  con- 
ditions may  give  rise  to  amentia  unaided,  the  number  of  cases  solely 
and  simply  due  to  them  is  relatively  small,  and  for  the  most  part 
their  influence  is  contributory  or  exciting  only. 

1.  Traumatic. — An  injury  to  the  child's  head  in  the  early  months, 
of  life,  or  whilst  it  is  still  within  the  uterus,  is  a  frequently  alleged 
cause  of  mental  defect ;  but  in  most  cases  careful  inquiry  will  serve- 
to  show  the  extremely  trivial  nature  of  the  injury  received,  and  will 
make  it  abundantly  clear  that  it  could  have  no  connexion  with 
the  patient's  deficiency.  In  other  cases,  however,  the  serious  con- 
dition of  the  patient  leaves  no  room  for  doubt  that  a  severe  trauma 
has  been  inflicted,  and  I  believe  that  in  a  small  number  of  cases 
this  may  be  followed  by  amentia.  In  such  cases  it  is  probable  that 
rupture  of  vessels  has  taken  place,  leading  to  cortical  laceration 
with  subsequent  destruction  of  a  localized  area  of  brain  tissue,  and 
in  most  of  these  patients  the  amentia  is  accompanied  by  epilepsy 
or  paralysis. 

2.  Toxic. — In  a  certain  proportion  of  cases  of  acute  infectious 
disease  occurring  in  infancy,  such  as  scarlet  fever,  enteric,  whoop- 
ing-cough, diphtheria,  and  measles,  as  well  as  in  otitis  and  rhinitis, 
there  are  definite  signs  that  a  cerebral  lesion  has  been  produced. 
Perhaps  in  some  of  these  affections  (particularly  pertussis)  the  lesion 
is  a  cortical  or  meningeal  haemorrhage ;  but  in  most  the  sjonptoms 
rather  point  to  a  direct  poisoning  of  the  brain  cells;  accordingly  I 
have  grouped  them  together  as  "  toxic."  In  addition  to  these  it 
seems  now  certain  that  the  brain  or  its  meninges  may  be  primarily 
affected  by  the  Diplococcus  intracellularis,  and  by  a  process  analogous 
to  acute  anterior  poliomyelitis.  The  majority  of  children  so 
affected  die;  others  make  a  complete  recovery;  whilst  in  a  few 


The  Causal  Factors  of  Amentia  6i 

others  death  does  not  take  place,  but  a  permanent  legacy  remains 
in  the  form  of  paralysis,  epilepsy,  or  amentia.  I  shall  refer  to  these 
cases  again  in  considering  the  pathological  and  clinical  features  of 
secondary  amentia;  here  it  will  be  sufficient  to  state  that,  although 
toxic  processes  of  this  kind  may  undoubtedly  produce  amentia,  the 
number  of  such  cases  is  relatively  small.  In  exceptional  instances 
the  amentia  may  be  caused  indirectly,  in  consequence  of  the  morbid 
process  involving  the  organs  of  special  sense,  or  by  "  sense  de- 
privation." 

It  is  probable  that  the  variety  of  amentia  known  as  "  infantile 
cerebral  degeneration  "  or  "  amaurotic  family  idiocy  "  is  really  due 
to  some  form  of  toxin,  although  the  pathogenesis  of  this  disease  is 
as  yet  very  obscure. 

Sunstroke,  although  frequently  alleged,  is  not  really  a  very 
common  cause  of  mental  defect.  I  have,  however,  seen  three  cases 
in  which  the  closest  inquiries  failed  to  reveal  any  other  cause,  so 
that  I  am  disposed  to  think  that  the  exposure  of  a  young  infant  to 
a  very  hot  sun  may  occasionally  produce  a  cerebral  lesion  and  lead 
to  an  arrest  of  development.  In  two  of  the  cases  the  exposure 
occurred  in  India;  in  the  third,  in  this  country  during  a  very  hot 
summer,  and  all  of  them  were  attended  with  unconsciousness.  It 
is  likely  that  many  of  the  cerebral  illnesses  of  childhood  attributed 
to  sunstroke  are  really  the  result  of  microbic  infection. 

The  above  are  the  chief  etiological  factors  responsible  for  the 
gross  cerebral  lesions  which  sometimes  lead  to  amentia.  In  addi- 
tion, cerebral  new  growths  may  occasionally  so  act. 

3.  Convulsive. — Convulsions  of  some  kind  or  other  are  amongst 
the  most  frequently  alleged  causes  of  amentia;  but  it  is  easy  to 
mistake  cause  for  effect,  and  my  experience  is  that  in  the  great 
majority  of  cases  where  the  two  are  associated  in  early  life,  both 
conditions  are  manifestations  of  a  neuropathic  diathesis.  At  the 
same  time  it  is  perfectly  obvious,  from  what  we  know  of  the  degrad- 
ing effects  of  epileptic  convulsions,  that  the  presence  of  severe  fits 
at  a  time  when  brain  development  is  still  incomplete  will  have 
a  most  prejudicial  effect,  and  it  is  highly  probable  that  the  child 
who  is  subject  to  frequent  convulsions  in  the  first  few  years  of  life 
will  fail  to  attain  normal  mental  development. 

A  good  deal  of  importance  has  been  attached  to  teething  con- 
vulsions, and  Dr.  Shuttleworth  found  these  present  in  nearly  one- 
third  of  the  admissions  to  the  Royal  Albert  Asylum.     It  is  often 


62  Causation 

assumed  that  convulsions  of  this  kind  are  totally  different  from 
those  of  epilepsy,  but  as  a  matter  of  fact  there  is  no  clear  line  of 
division  between  the  two.  It  is  exceedingly  rare  for  the  child  whose 
inheritance  is  good  to  suffer  in  this  way,  although  his  gums  may  be 
extremly  painful  and  swollen,  and  it  will  often  be  found  that  where 
convulsions  are  present  during  teething,  the\'  recur  in  later  life  as 
ordinary  epilepsj^;  indeed.  Sir  WUHam  Gowers  states  that  "a 
considerable  number  of  cases  of  epilepsy  date  from  infantile  con- 
vulsions." In  the  absence  of  a  neuropathic  predisposition  infantile 
eclampsia,  independently  of  brain  disease,  is  exceedingh'  rare, 
and  amentia  due  solely  and  simply  to  this  cause  probably  hardly 
ever  occurs. 

4.  Nutritional. — A  very  important  question,  from  the  point  of 
view  of  prevention,  is  that  of  the  possibility  of  mental  defect  being 
caused  by  defective  bodily  nutrition.  It  is  a  well-known  fact  that 
the  physical  health  and  development  of  the  growing  child  is  very 
greatly  dependent  upon  the  quantity  and  quality  of  its  food,  the 
presence  of  an  adequate  amount  of  sleep,  fresh  air,  light,  warmth, 
etc.  Consequently  it  might  be  assumed  that  these,  by  influencing 
its  general  nutrition,  would  have  a  corresponding  effect  upon  its 
brain  development.  There  is  no  doubt  that  adverse  conditions  in 
these  respects  may  retard  mental  development,  and  the  same  result 
may  foUow  serious  ill-health  or  disease.  I  have  indeed  seen  a  few 
cases  where  the  developmental  arrears  have  never  been  fuUy  made 
up,  so  that  a  condition  of  permanent  amentia  has  resulted.  But 
such  cases  are  very  rare,  and  on  the  whole  it  may  be  said  that 
these  factors,  in  the  absence  of  hereditary  predisposition,  have 
comparatively  little  causal  influence.  The  same  ma\'  be  said  of 
shock  and  fright.  It  is  exceedingly  doubtful  whether  these  have 
ever  caused  amentia  in  a  normal  child,  although  they  ma\'  pre- 
cipitate it  in  one  with  hereditary  predisposition.  Rickets  is  sometimes 
the  accompaniment  of  mental  deficienc}',  but  I  doubt  whether  it  is 
ever  its  cause.  One  particular  variety  of  defect,  however,  cretinism,  is 
undoubtedly  due  to  the  deprivation  of  a  specific  nutriti\-e  material. 

Etiological  Factors  in  Regard  to  Local  Variations  of  Incidence. 

Before  concluding  this  account  of  causation,  it  is  necessary  to 
refer  to  the  connexion  existing  between  certain  etiological  factors 
and  local  variations  in  the  prevalence  of  amentia. 

We  have  already-  seen  (Chapter  II.)  that  the  incidence  of  amentia 


The   Causal   Factors  of  Amentia  63 

is  not  unifonii  throughout  the  country,  but  that  in  some  locahties 
it  is  relatively  much  higher,  and  in  others  much  lower,  than  the 
mean  average.  Into  the  cause  of  this  inequality  I  do  not  propose 
to  enter,  for  it  is  but  part  of  a  similar  variation  in  the  incidence  of 
mental  disease  in  general,  and  is  therefore  beyond  the  scope  of  our 
subject.  But  there  are  certain  variations  in  the  incidence  of  amentia 
relative  to  other  forms  of  mental  disease,  and  in  the  incidence  of 
the  degrees  of  amentia  relative  to  one  another,  which  are  so  closely 
connected  with  the  question  of  causation  that  they  must  be  re- 
ferred to. 

The  Incidence  of  Amentia  Relative  to  Insanity. — The  statistics 
of  the  Royal  Commission  show  that,  broadly  speaking,  insanity  is 
more  characteristic  of  the  urban  and  industrial,  and  amentia  of  the 
rural,  populations  of  this  country.  We  have  already  seen  that  the 
causes  of  these  two  conditions  are  identical  in  kind — namely,  neuro- 
pathic inheritance — but  that  they  differ  in  degree,  inasmuch  as  the 
inheritance  is  usually  more  pronounced  in  amentia  than  in  insanity. 
Now,  the  towns  have  been  built  up  and  are  being  steadily  increased 
by  the  immigration  of  persons  from  the  country,  and  it  is  justifiable 
to  conclude  that  the  persons  so  migrating  will  possess  the  qualities 
of  initiative,  enterprise,  and  mental  vigour  in  a  higher  degree  than 
those  who  are  content  to  remain  upon  the  land — that,  in  short,  a 
comparatively  smaller  proportion  of  them  will  come  of  a  pro- 
nounced neuropathic  stock.  This  process  inevitably  tends  to  the 
accumulation  in  the  rural  districts  of  those  most  saturated  with 
morbid  heredity,  a  state  of  affairs  which  is  often  accentuated  by 
intermarrying,  and  so  the  conditions  in  these  areas  become  more 
and  more  favourable  to  the  production  of  actual  mental  defect. 
On  the  other  hand,  in  our  towns  and  thickly  populated  industrial 
centres  competition  is  keen,  the  stresses  and  strains  of  life  are 
severe,  alcoholism  is  rife,  consumption  is  very  prevalent,  narrow 
streets  are  densely  packed  with  overcrowded  houses,  women  ad- 
vanced in  pregnancy  continue  to  work  in  the  mills  and  factories, 
infants  who  should  be  at  the  breast  are  reared  artificially,  and,  in 
short,  all  the  conditions  are  present  necessary  to  produce  an  in- 
stability of  the  higher  parts  of  the  nervous  system — the  precursor 
of  insanity.  This,  in  subsequent  generations,  may  possibly  lead 
to  germinal  defect  and  consequent  amentia,  but  the  constant  im- 
migration drags  fresh  blood  into  the  vortex,  and  tends  to  make 
insanity  rather  than  amentia  the  prevailing  type  of  mental  abnor- 
mality. 


64  Causation 

The  Relative  Incidence  of  the  Different  Degrees  of  Amentia. — 

As  has  been  shown  in  Chapter  II.,  not  only  is  amentia  absolutely 
more  prevalent  in  rural  than  in  urban  districts,  but  the  grosser 
degrees  of  defect  are  relatively  in  excess  also;  whilst  in  the  towns 
mentally  defective  children  are  relatively  and  absolutely  more 
prevalent  than  in  the  country.  I  am  of  opinion  that  there  are 
three  chief  factors  of  town  life  which  tend  to  bring  about  this  result 
— namely,  (i)  a  lessened  production,  (2)  an  increased  destruction  of 
the  more  severe  grades  of  defect,  and  (3)  the  presence  in  the  towns 
of  cases  of  delayed  development  which  simulate  mental  defect,  and 
so  cause  an  apparent  increase  in  the  incidence  of  amentia. 

(i)  Lessened  Production  of  Severe  Defect :  This  is  due  to  the  same 
causes  which  bring  about  a  diminished  incidence  of  amentia  gener- 
ally— namely,  a  lessened  neuropathic  heredity  in  the  town  dwellers. 
(2)  Increased  Destruction  of  Severe  Defect:  I  am  unable  to  give 
any  statistical  proof  of  this,  but  I  think  it  is  probable  that  the 
relatively  higher  infantile  mortality  of  the  towns  may  be  not 
without  effect  in  causing  a  diminution  of  the  worst  grades  of  defect 
in  these  situations,  since  the  mortality  of  aments  would  seem  to  be 
directly  proportionate  to  the  degree  of  defect.  (3)  It  has  already 
been  remarked  that  a  small  proportion  of  cases  of  secondary 
amentia  are  the  result  of  a  faulty  environment,  and  this  I  believe 
to  be  more  prevalent  in  town  than  country.  But  as  we  shall  see 
in  considering  mentally  defective  children,  there  is  a  condition  of 
delayed  development  which  is  very  much  more  common  in  densely 
congested  areas,  and  which  simulates  real  amentia  very  closely.  I 
believe  this  is  responsible  in  no  slight  degree  for  the  apparent  in- 
crease of  the  juvenile  feeble-minded  in  towns.  In  corroboration  of 
this  is  the  fact  that  in  the  towns  there  is  no  relative  increase  of  the 
adult  feeble-minded.  It  is  probably  true  that  a  small  proportion 
of  the  male  feeble-minded  actually  born  in  the  towns  are  gradually 
squeezed  further  afield  in  the  struggle  for  existence ;  this,  however, 
is  in  all  likelihood  balanced  by  an  influx  of  feeble-minded  women 
from  adjacent  country  districts. 

The  following  family  history  charts  afford  graphic  illustrations 
of  many  of  the  points  referred  to  in  this  chapter. 

In  them  amentia,  insanity,  or  epilepsy,  is  shown  as  •  ;  alcoholism, 
tuberculosis,  general  ill-health,  neuroses,  and  premature  death,  as 
@ ;  whilst  persons  presumably  healthy,  dying  from  natural  causes, 
or  of  whom  no  information  is  obtainable,  are  shown  as  O. 


Family  History  Charts 


65 


CHART  I. 
SHOWING  HEALTHY  ANCESTRY  +  SLIGHT  ALCOHOLIC  ANCESTRY. 


Country 


f/o  ir^ormat\on\^ 


ihhihi 


/■firi  %h^    ^Xi    Jt, 


ConswncCien     2         CansumpCtai         Hindti  ^l^      0  ,       0  J'  ^      s:» 


^^   2f    2'-^  J^^ 


i 


Case  No.  131,  W.  J.  G. 


CHART  II. 

SHOWING  HEALTHY  ANCESTRY    +    PATHOLOGICAL  ANCESTRY. 


3} 


^^ 


Case  No.  10,  A.  C. 


66 


Causation 


CHART  III. 

SHOWING  HEALTHY  ANCESTRY  +  INSANE  ANCESTRY. 


/Hii^aSO  £>t.sd^ 


yV(7  cnfOT'^  aft  c 


It 


^ee&c^  /-^enc^eci . 


6-2  /iU  W^>^  ^•i  cctCCAy 


1 


Case  No.  5,  /.  W.  J. 


CHART  IV. 
SHOWING  THE  EFFECT  OF  INSANE   +    PHTHISICAL  ANCESTRY. 


/■oJc*"    Satcf  /diot    Sard  /ft^<i!xr-r-i.aa= 


Case  No.  99,  F.  W. 


Family  History  Charts 


67 


CHART  V. 

SHOWING  EFFECT  OF  ALCOHOLIC  AND  INSANE  ANCESTRY] 
+    PHTHISICAL  ANCESTRY. 


i  ^  ^  ^  dfUcai*  ■^^     2  ^ 


-^.-^   ill 

n*  si 
^1 


Case  No.  174,  C.  B. 

CHART  VI. 
SHOWING  THE  EFFECT  OF  DOUBLE  MORBID  ANCESTRY. 


y^'^fj'' 


Z>>^^c£      ^c'^a:^ 


IhS. 


^ci-c^  g^Cc 


•V" 


y?<2/'a^ysts>. 


6\^      \^      \±      \^     \^      \t     1^        ^     XF     \i^     \i^    Xr^   \c^   X:^   J^'^ 
%m  ooomo  %  0%  m 6 o  o • 


■t  ^  b 


J:    »•(«    A^   ))b 


■Sc3/  d  £o  ifc 


Case  No.  9,  S.  V. 


68 


Causation 


CHART  VII. 

SHOWING  THE  EFFECT  OF  DOUBLE  MORBID  ANCESTRY. 


k)k 


Z)i  ecf  £n  C/'Ud/jocc/ 


5^  V?. 


^ 


/o  r  6Monl/t  s 


Case  No.  83,  W.  A.  M. 


CHART  VIII. 

SHOWING  THE  EFFECT  OF  A  DOUBLE  INSANE  ANCESTRY 

+   SYPHILIS. 


Said  ecieAexx!'^   A'carofcc 

I  4  i  #  •  6  • 


^s  Is  II 
'-2  S^^  M 


^ 


I5 


\%    ^ 


Case  No.  97,  P.  W. 


Family  History  Charts 


69 


CHART  IX. 

SHOWING  THE  EFFECT  OF  CONSANGUINITY  IN  A  FAMILY  WITH 
A  TENDENCY  TO  VASCULAR  LESIONS  OF  THE  BRAIN, 


2&    ^^^  >S?^    »^§ 


Case  No.  70,  F.  E.  V. 


Note  on  Maternal  Impressions  (p.  56). — In  view  of  the  extreme  rarity 
of  authentic  cases  of  amentia  due  to  maternal  impressions,  the  following 
letter,  which  I  have  received  as  this  book  is  going  through  the  press,  merits 
quotation : 

"  Dear  Sir, 

"  I  cannot  vouch  for  the  actual  veracity  of  the  case,  but  this  morning 
a  man  told  me  that  some  time  ago  a  woman,  expecting  a  child,  was  frightened 
by  a  hen,  and  that  the  child,  when  born,  had  a  little  finger  with  a  claw.  This 
has  been  removed  by  a  surgical  operation.  The  child,  however,  has  now, 
as  the  man  described  it,  the  disposition  of  a  hen,  and  is  destructive,  savage, 
and  unmanageable.     Now,  can  you  tell  me  what  home  could  be  found  for 

this  child  ?     The  D Board  of  Guardians  would,  I  believe,  be  willing  to 

pay  for  its  maintenance.     There  is,  I  know,  some  home  at  G .     I  do  not 

know  whether  this  place  would  be  suitable.     I  cannot  say  how  much  obliged 
I  shall  be  by  any  information  that  you  can  give  me . 


"  Very  truly  yours, 
"  X Y- 


"  November  2^th,  1913. 


Obviously  the  most  suitable  place  for  this  case  would  be  a  poultry  farm. — 
A.  F.  T. 


CHAPTER    IV 

PATHOLOGY 

Before  discussing  the  pathology  of  amentia,  it  will  be  useful  if  I 
allude  to  the  salient  features  regarding  cerebral  development. 

Development  of  the  Normal  Brain. 

The  first  indication  of  the  brain  is  seen  very  shortly  after  fertiliza- 
tion of  the  germ  cell,  and  consists  in  an  expansion  of  the  anterior 
end  of  the  rudimentary  spinal  cord  to  form  four  primary  cerebral 
vesicles.  It  is  by  a  series  of  elaborate  infoldings  of  these  vesicles, 
and  by  the  multiplication  around  them  of  the  cells  composing  their 
walls,  that  cerebral  development  takes  place.  By  the  time  the 
embryo  is  six  months  old  the  brain  has  assumed  the  general  shape 
of  the  adult,  although  there  is  as  yet  a  complete  absence  of  all  those 
secondary  fissures  and  convolutions  which  are  such  a  characteristic 
feature  of  the  fully  developed  organ. 

At  birth  many  of  these  convolutions  are  present,  and  the  brain 
weighs*  from  280  to  330  grammes.  During  the  first  six  months  of 
life  growth  is  exceedingly  rapid,  the  weight  of  the  brain  at  the  end 
of  this  time  being  more  than  double  what  it  was  at  birth — ^namely, 
from  600  to  680  grammes.  By  the  end  of  the  first  year  the  weight 
has  reached  about  750  grammes,  and  from  this  onward  it  still  con- 
tinues to  grow  until  the  age  of  twelve  or  fourteen  years,  when  its 
average  weight  is  1,150  grammes  in  the  female  and  1,300  grammes 
in  the  maJe.  A  further  slight  increase  takes  place  during  the  next 
seven  years,  and  at  the  age  of  twenty-one  the  brain  has  attained 
the  average  weight  of  1,244  grammes  in  the  female  and  1,374 
grammes  in  the  male.  From  this  period  growth  is  very  slow,  imtil, 
according  to  Broca  and  Peacock,  the  maximum  average  weight  of 
1,269   grammes   (45   ounces)    in  the   female   and    1,421   grammes 

*  According  to  R.  Boyd,  Phil.  Trans.,  1S60. 
70 


Development  of  the  Normal  Brain  71 

(50  ounces)  in  the  male  is  attained  between  twenty-five  and  thirty- 
five  years  of  age. 

This  progressive  increase  in  size  and  weight  is  due,  firstly,  to  the 
rapid  multiplication,  and  secondly,  to  the  individual  development, 
of  the  nerve  cells.  These  arise  from  the  cells  lining  the  floor  of  the 
primitive  cerebral  vesicles,  and  at  first  they  are  of  one  uniform 
indifferent  type.  Subsequently,  however,  differentiation  occurs, 
and  features  appear  which  are  characteristic,  and  which  persist 
throughout  life.  It  is  as  a  result  of  this  differentiation  that  the 
brain  cortex  acquires  its  peculiar  laminated  appearance.  Coincident 
with  lamination  delicate  protoplasmic  processes  arise  from  these 
nerve  ceUs,  and,  pursuing  definite  directions  throughout  the  cerebral 
mass,  constitute  the  association  and  projection  systems  of  fibres. 
The  former  serve  to  link  together  in  the  most  complicated  manner 
aU  parts  of  the  brain ;  they  also  compose  the  great  association  centres 
of  Flechsig ;  the  latter  are  the  pathways  by  which  the  brain  is  con- 
nected with  the  various  parts  of  the  body. 

Development  does  not  proceed  at  the  same  rate  in  all  parts  of 
the  brain  simultaneously.  The  nerve  cells  of  certain  areas  reach 
maturity  much  earlier  than  do  those  elsewhere,  and  the  frontal  and 
parietal  regions,  which  there  is  good  reason  for  thinking  are  those 
most  concerned  with  the  highest  intellectual  functions,  are  the  last 
to  acquire  their  mature  characteristics.  In  the  frontal  lobes  of  the 
seven-months  embryo  lamination  has  not  yet  appeared,  and  the 
cells  are  of  a  uniform  undifferentiated  type  (neuroblasts).  These 
are  small  round  cells  with  a  close  and  readily  stainable  reticulum, 
but  quite  devoid  of  processes,  and  they  lie  embedded  in  a  matrix 
which,  in  the  hardened  and  stained  section,  somewhat  resembles 
the  grain  of  marble.  In  the  eight-months  embryo  the  neuroblasts 
are  somewhat  larger,  the  reticulum  is  less  close  and  has  less  affinity 
ior  stain,  but  there  are  as  yet  no  definite  processes.  As  this  age  it 
is  possible  to  make  out  the  beginning  of  lamination  in  this  region 
of  the  cortex.  In  the  child  of  two  weeks  old  (extra-uterine)  the 
cells  have  made  a  considerable  advance,  and  they  are  now  readily 
recognizable  as  nerve  cells.  A  cell  body  is  present,  although  the 
protoplasm  of  this  differs  greatly  from  the  mature  cell,  being  very 
vacuolated,  and  liable  to  break  away  from  the  nucleus.  At  this 
age  also  the  cells  of  the  pyramidal  layer  possess  an  apical  process, 
and  occasionally  other  processes  are  present;  but  the  apical  one 
is  always  the  best  developed,  and  appears  to  be  the  first  formed. 


72  Pathology 

Finally,  a  few  years  after  birth  the  cell  has  assumed  its  mature 
character,  and  possesses  axons,  dendrons,  and  gemmules.  In  other 
regions  of  the  brain  development  takes  place  earlier,  and  in  the 
motor  area  of  the  eight-months  embryo  medium-sized  pyramidal 
and  also  Betz'  cells  are  readily  recognizable.  Indeed,  Dr.  J.  S. 
Bolton*  says  that  the  Betz'  cell  area  can  be  accurately  mapped  out 
as  early  as  the  eighteenth  week  of  embryonic  existence. 

The  processes  of  the  fully  developed  nerve  cells  communicate 
with  one  another  (physiologically,  if  not  anatomically)  in  an  ex- 
ceedingly complicated  network,  forming  the  bands  and  systems  of 
association  fibres  already  mentioned.  It  is  by  means  of  them  that 
nervous  impulses  travel  to  and  from  all  parts  of  the  cerebro-spinal 
system,  and  it  has  even  been  suggested  that  the  nerve  cell  is  of 
secondary  importance,  and  only  serves  the  purposes  of  nutrition. 
However  this  may  be,  there  is  a  definite  relation  between  the  appear- 
ance of  the  cell  as  seen  under  the  microscope  and  the  state  of  the 
fibre,  and  the  condition  of  the  cells  forms  a  convenient  and  rehable 
index  of  the  presence  of  disease. 

There  can  be  no  doubt  that  the  number  and  complexity  of  the 
cell  processes,  particularly  those  forming  the  association  systems, 
are  intimately  connected  with  the  degree  and  complexity  of  cerebral 
activity,  and  it  is  highly  probable  that  the  intellectual  expansion 
v/hich  takes  place  after  puberty  is  due  to  their  numerical  increase 
and  the  elaboration  of  their  connexions.  It  has,  indeed,  been  shown 
by  Kaest  that  a  progressive  increase  in  these  fibres  can  be  demon- 
strated up  to  the  middle  period  of  life,  after  which  he  states  that 
growth  ceases  and  a  gradual  diminution  takes  place. 

Finally,  to  complete  this  brief  resume,  it  may  be  said  that  the 
nerve  cells  and  fibres  are  embedded  in  a  network  of  supporting  tissue 
(neuroglia  ceUs  and  their  processes),  encased  in  a  series  of  delicate 
connective-tissue  membranes  (the  meninges)  and  the  whole  organ 
permeated  by  a  dense  ramification  of  bloodvessels. 

Whatever  may  be  the  relation  of  mind  to  brain,  it  is  now  fully 
recognized  that  the  manifestation  of  mental  activity  is  indissolubly 
connected  with  the  cells  of  the  cerebral  cortex.  Mind  develops  pari 
passu  with  their  growth,  and  fails  with  their  decay.  Dementia  is 
coincident  with  their  degeneration  and  death,  and,  as  will  presently 

*   J.  S.  Bolton  and  Moyes,  Brain,  1912,  vol.  xxxv.,  part  i. 
t  T.  Kaes,  Monatsschrift  fily  Psychiatric  und  Neurologic,  1897;  also  "  Die 
Grosshirnrinde, "  etc.,  Jena,  1907. 


The   Pathology  of  Amentia  73 

be  shown,  amentia  is  associated  with  their  incomplete  develop- 
ment. 

It  is  apparent  from  this  outline  of  cerebral  development  that  the 
period  of  greatest  growth  is  that  between  the  first  appearance  of 
the  primitive  brain  and  the  end  of  the  sixth  month  of  extra-uterine 
life;  consequently,  it  is  during  this  period  that  the  demands  upon 
the  environment  are  greatest,  and  that  any  adverse  factor  will  be 
most  severely  felt.  This  entirely  accords  with  the  general  experience 
that,  where  secondary  amentia  occurs,  it  is  the  result  of  an  adverse 
environment  during  the  early  months  of  life.  The  mental  develop- 
ment which  takes  place  after  puberty  appears  to  be  the  result  of 
the  elaboration  of  association  systems,  and  although,  theoretically, 
developmental  arrest  might  occur  at  this  time,  such  would  but  rarely 
be  likely  to  result  in  any  pronounced  deficiency.  On  the  other 
hand,  in  cases  of  primary  amentia,  the  condition  is  rather  one  of  a 
general  inability  to  develop  than  of  an  arrest  of  development,  and 
the  cause  is  in  existence  anterior  to  the  very  beginning  of  em- 
bryonic existence. 

THE  PATHOLOGY  OF  AMENTIA. 

Many  mistaken  notions  still  exist  with  regard  to  the  pathology 
of  amentia.  As  we  shall  presently  see,  in  a  very  considerable 
number  of  these  patients,  particularly  the  lower  grades,  there  exist 
gross  abnormalities  of  brain  structure,  or  severe  and  extensive 
morbid  conditions,  which  are  visible  to  the  naked  eye.  Accordingly, 
it  was  not  unnatural  that  the  earlier  observers,  examining  isolated 
cases,  in  the  days  when  much  less  was  known  about  the  structure 
of  the  nervous  system  than  is  the  case  at  present,  should  conclude 
that  in  these  various  anomalies  they  saw  the  fans  et  origo  of  the 
mental  defect.  As  a  consequence,  amentia  was  variously  attributed 
to  the  presence  of  porencephaly,  hemiatrophy,  microgyria,  and  the 
like.  These  views  cannot  be  held  to-day.  In  the  first  place,  it 
has  been  abundantly  shown  that  such  conditions  may  exist  without 
any  mental  defect  or  deterioration  whatever;  whilst,  secondly,  an 
increased  knowledge  of  the  structure  of  the  nervous  system,  and 
particularly  of  the  nerve  cell,  together  with  a  greatly  improved 
technique,  has  clearly  demonstrated  the  existence  of  important 
cellular  changes  in  amentia. 

In  support  of  the  statement  that  these  gross  conditions  cannot 
really  be  the  cause  of  mental  defect,  the  following  observations 


74  Pathology 

may  be  cited:  About  thirty  cases  have  been  recorded  of  absence 
or  deficiency  of  the  corpus  callosum,  most  of  them  in  idiots,  yet 
Nobihng- Jolly,  Eichler,  and  Klob  have  each  recorded  a  similar  case 
in  which  there  was  no  mental  peculiarity.  Likewise  with  another 
frequent  accompaniment  of  amentia— porencephaly.  Several  cases 
have  been  described  in  which  a  large  cavity  existed  in  one  hemi- 
sphere, and  yet  there  was  little  or  no  appreciable  mental  change. 
Schroeder  van  der  Kolk*  mentions  a  number  of  instances  tending 
to  show  that  a  large  proportion  of  one  hemisphere  may  be  diseased, 
and  yet  the  patient  show  no  mental  impairment.  Finally,  with 
regard  to  another  condition — hydrocephalus— Freudf  states  it  to 
be  an  undoubted  fact  that  severe  hydrocephalus  may  exist  without 
any  paralytic  symptoms ;  whilst  Ziegler J  states  that  such  malforma- 
tions, or  even  still  greater  defects,  may  exist  in  the  brain,  though 
during  life  there  was  nothing  whatever  to  indicate  their  presence. 

We  cannot  but  conclude,  therefore,  that  although  these  gross 
changes  are  frequently  associated  with  amentia,  they  are  not 
essential  to  that  condition,  and  in  discussing  the  question  of  patho- 
genesis we  must  be  careful  clearly  to  distinguish  between  what  is 
essential  and  what  is  only  accidental. 

At  the  same  time  it  is  undeniable  that  gross  malformations  and 
coarse  lesions  are  much  commoner  in  the  epileptic  and  mentally 
defective  than  in  normal  persons,  and  it  is  easy  to  understand,  from 
the  description  which  has  been  given  of  the  causation  and  hereditary 
predisposition  of  these  persons,  that  such  should  be  the  case.  On 
the  other  hand,  there  is  no  doubt  that  certain  morbid  processes 
may,  even  in  the  previously  healthy  brain,  produce  such  an  arrest 
of  neuronic  development  as  to  bring  about  amentia. 

The  essential  basis  of  amentia  is  an  imperfect  or  arrested  de- 
velopment of  the  cerebral  neurones,  a  fact  which  is  now  established 
beyond  doubt  by  careful  microscopical  examinations  conducted  by 
numerous  competent  observers.  This  morbid  state  of  the  neurones 
is  brought  about  by  the  causes  which  have  already  been  described 
in  Chapter  II.  Accordingly,  I  shall  first  of  all  describe  these  histo- 
logical changes,  relegating  the  various  gross  anomalies  and  diseased 
conditions  to  a  second  place. 

*   Schroeder  van  der  Kolk,  Sydenham  Society  Transactions,  1861. 
t   Freud,  "  Infantile  Cerebral  Lahmung,"  Wien,  1S97. 
I   Ziegler,  "  Textbook  of  Special  Pathology,"  1S96. 


Plate  I. 


Fibres 


Fig.  g. — Microscopical  Sections  of  the  Frontal  Cortex  in  Dementia,  Amentia,  and  the 
Normal  Conditions  (Semi-Diagrammatic,  drawn  by  A.  F.  Tredgold). 

On  the  left  of  each  are  shown  t)x&Jilires  as  they  appear  m  sect'oiis  stainedby  the  Marchi-Pal 
method,  on  the  right  the  cells  as  they  appear  in  Nissl  sections.  The  various  laj'ers  are  as 
follows : 

Fibres. — (i)  Tangential,  chiefly  formed  by  the  ramifications  of  the  collateral  processes  from 
cells  at  A,  B,  C,  and  £>,  also  the  terminals  of  some  of  the  fibres  forming  the  medullary  rays. 
This  line  is  normally  well  defined  ;  in  amentia  it  is  somewhat  diminished,  in  dementia  markedly 
so.  (2)  Siiper-radial.  A  few  horizontally-coursing  fibres  are  situated  here,  but  this  region  is 
chiefly  occupied  by  cells  (/>).  (3)  Oute7-  line  of  Baillarger  (line  of  Vicq  d'.\zyr),  horizontally- 
coursmg  fibres  composed  of  collaterals  from  cells  at  B,  C,  and  D,  a  well-marked  line  normally, 
much  diminished  in  amentia  and  dementia.  (4)  Inter-radial,  a  less  definite  bundle,  probably  of 
similar  constitution  to  (3),  diminished  in  amentia  and  dementia.  (5)  White  matter  of  centrum 
ovale.  The  vertical  bundles  are  composed  of  axones  from  B,  C,  and  £>,  and  of  meduUated  fibres 
from  other  regions  of  the  br.ain. 

Cei.i.s. — (A)  Neuroglia  and  small  irregular  nei-ve  cells  {molecular  laye?-).  (/>')  External 
granules.  (C)  Small  a.nA{D)  ^fedium  pyramids.  In  amentia  there  are  comparatively  few  cells 
in  these  layers,  and  those  present  are  irregular  in  arrangement  and  of  incomplete  development  ; 
in  dementia  many  of  these  cells  are  in  an  advanced  state  of  degeneration.  (A')  Large  pyramids^ 
similar  changes  to  those  in  the  preceding  layers,  but  not  so  extensive.  (/•')  I'>ee/>  granuL-s  and 
polynw7-phous  cells.  It  will  be  noticed  that  in  amentia  the  whole  cortex  is  much  thinner  than  in 
the  normal  condition.  This  is  principally  due  to  the  defective  development  of  the  cells  at  C,  D,  E, 
and  F,  but  especially  to  those  at  C  and  D  and,  according  to  Roncoroni,  at  F. 


To  face  page  t  4.]- 


The  Histology  of  Primary  Amentia  'j  z^ 

The  Histology  of  Primary  Amentia. 

Nerve  Cells  of  the  Brain  Cortex. — As  compared  with  the  nerve 
cells  of  the  healthy  brain,  those  of  the  ament  are  characterized  by 
the  following  conditions:  (i)  Numerical  deficiency;  (2)  irregular 
arrangement;  (3)  imperfect  development  of  individual  cells;  and 
on  the  whole  it  may  be  stated  that  the  amount  of  change  discover- 
able by  the  microscope  is  directly  proportionate  to  the  degree  of 
mental  deficiency  present  during  life. 

1.  'Numerical  Dd/cjencj/.— Although  an  actual  enumeration  of 
the  nerve  cells  present  in  these  cases  cannot  be  made,  I  am  convinced, 
from  the  careful  examination  of  a  large  number  of  sections,  that  the 
cells  composing  the  grey  matter  of  the  cerebral  cortex  are  decidedly 
fewer  than  in  the  normal  brain.  In  many  cases  this  paucity  of  cells 
produces  a  decrease  in  the  thickness  of  the  cortical  grey  matter 
which  is  obvious  to  the  naked  eye  (see  Fig.  9,  Plate  I.).  Further, 
although  the  cells  of  all  the  layers  are  fewer  than  normal,  it  is  the 
small  and  medium-sized  pyramids  which  are  most  diminished  in 
number.  Hammarberg,  as  the  result  of  a  most  elaborate  and 
careful  series  of  observations,  arrived  at  a  similar  conclusion. 

2.  Irregular  Arrangement. — Hammarberg*  states  that  the  ar- 
rangement of  the  cortical  cells  in  amentia  does  not  differ  from  the 
normal;  but  my  own  experience,  as  also  that  of  several  other  ob- 
servers, is  to  the  effect  that  an  irregular  and  haphazard  arrangement 
is  very  characteristic  of  this  condition.  The  pyramidal  cells  show 
the  most  change,  although  this,  of  course,  may  be  simply  due  to  the 
fact  that  the  form  of  these  cells  renders  any  irregularity  more 
apparent.  Throughout  the  brain  there  are  in  this  layer  numbers 
of  cells  lying  horizontally,  obliquely,  or  completely  upside  down, 
even  where  there  is  no  accompanying  sclerosis,  and  where  sclerosis 
is  present  the  irregularity  is  often  extreme. 

3.  Imperfect  Development. — As  early  as  1879  Bevan  Lewisf  drew 
attention  to  the  presence,  in  certain  forms  of  amentia,  of  incom-. 
pletely  developed  nerve  cells,  and  similar  cells  were  present  in  cases 
which  I  examined.  When  stained  by  Nissl's  method  they  ha^'e 
the  following  characteristics:  The  nucleus  is  large  and  ovoid  in 

*   Hammarberg,  "  Studien  iiber  Klinik  und  Pathologic  der  Idiotic,"  Upsala, 

1895- 

t  Bevan  Lewis,  "  Textbook  of  Mental  Diseases,"  1899;  also  Brain,  October, 
1879. 


76  •  Pathology 

shape;  the  nuclear  membrane  and  intranuclear  network  are  very- 
distinct.  The  nucleolus  is  often  eccentric,  so  that  in  some  sections 
it  cannot  be  seen.  The  cell  outline  is  distinct,  but,  instead  of  being 
pyramidal,  it  is  globular  or  p3Tiform  in  shape,  and  angles  are  com- 
pletely wanting.  The  processes  of  the  cell  are  exceedingly  few,  and 
in  many  instances  one  only  can  be  seen  (see  Frontispiece,  Fig.  4). 
This  paucitj^  of  dendrons  and  also  of  gemmules  is  still  more  evident 
in  sections  stained  by  the  silver  method. 

I  think  it  cannot  be  doubted  that  the  conditions  here  described  are 
due  to  incomplete  development.  I  have  never  seen  such  cells  in  any 
human  brain  other  than  that  of  an  ament ;  it  is,  however,  interesting 
to  note  that,  according  to  Bevan  Lewis,  similar  cells  exist  normally 
in  the  second  and  third  layers  of  the  cerebral  cortex  of  the  ape. 
Bevan  Lewis  was  only  able  to  discover  these  immature  cells  in  cases 
of  amentia  complicated  by  epilepsy,  and  he  thought  they  did  not 
occur  in  pure  amentia;  but  I  have  seen  them  in  cases  in  which 
epilepsy  was  absent. 

In  addition  to  the  above,  the  cerebral  cortex  of  the  pronounced 
ament  nearly  always  contains  a  large  number  of  other  cells  whose 
development  is  even  less  complete,  and  which  closely  resemble  the 
undifferentiated  neuroblasts  already  described  as  composing  the 
normal  frontal  cortex  up  to  the  eighth  month  of  embryonic  exist- 
ence. In  these  there  is  practically  no  cell  body,  or  at  most  a  few 
irregular  protoplasmic  strands;  the  nucleus  is  large  and  globular, 
the  intranuclear  network  very  distinct,  and  often  disposed  as 
several  fine  lines  which  divide  the  nucleus  into  compartments-.  In 
fact,  they  are  undifferentiated  and  undeveloped  neuroblasts,  and 
in  areas  of  localized  agenesis — such,  for  instance,  as  are  seen  in 
microgyria — there  is  often  no  other  kind  of  cell  to  be  seen  (see 
Frontispiece,  Fig.  i). 

There  is  another  condition  of  the  cortical  cells  which  is  exceed- 
ingly common  in  these  cases — namely,  pigmentation.  This  does 
not  occur  in  the  immature  cells  above  described,  and  is  chiefl}^  seen 
in  the  deeper  pyramidal  layer,  in  which  it  is  often  a  very  marked 
feature.  The  pigment  is  generally  situated  at  one  angle  of  the  cell, 
away  from  the  nucleus,  but  at  times  it  is  so  abundant  as  almost  com- 
pletely to  fill  the  cell  (see  Frontispiece,  Fig.  7) .  It  is  yellow  in  colour 
in  Nissl  or  polychrome  sections,  but  appears  dark  brown  or  almost 
black  in  those  stained  with  Marchi's  fluid,  and  hence  gives  to  these 
sections  a  most  striking  appearance.     In  several  of  my  cases  it  was 


The  Histology  of  Primary  Amentia  'j'j 

particularly  pronounced  in  the  cells  of  the  hippocampus  (see  Frontis- 
piece, Fig.  8).  The  exact  nature  and  significance  of  this  pigment  is 
unknown,  though  the  reaction  with  Marchi's  fluid  would  suggest 
that  it  was  of  a  fatty  nature.  I  have  seen  a  similar  pigmentation, 
but  to  nothing  like  the  same  extent,  in  the  central  nervous 
system  of  patients  who  have  suffered  from  chronic  nervous  disease 
{e.g.,  disseminated  sclerosis,  amyotrophic  lateral  sclerosis,  progres- 
sive muscular  atrophy,  chronic  insanity,  etc.).  Its  occurrence  in 
these  conditions  as  well  as  in  aments  would  suggest  that  it  is  an 
indication  of  defective  metabolism,  in  which  the  anabolic  processes 
cannot  keep  pace  with  the  katabolic.  The  pigment  is  nearly  always 
associated  with  a  diminution  in  the  number  and  size  of  the  Nissl 
bodies. 

Situation  of  the  Cellular  Changes. — With  regard  to  the  layers  in 
which  these  imperfections  are  most  evident,  it  was  stated  by  Bevan 
Lewis  that  embryonic  cells  were  particularly  numerous  in  the  layers 
of  small  and  medium  pyramids,  and  my  own  observations  are  en- 
tirely in  agreement  with  this.  Incompletely  developed  cells  occur, 
it  is  true,  in  all  the  cortical  layers,  and  in  extreme  cases  of  idiocy 
they  may  even  be  seen  in  the  spinal  cord ;  but  it  is  in  the  small  and 
middle  pyramidal  cells  that  the  greatest  change  is  evident.  In 
view  of  the  fact  that  these  cells  are  normally  amongst  the  last  to 
attain  their  full  development,  also  that  they  are  the  earliest  and  most 
affected  in  dementia  resulting  from  epilepsy  and  chronic  insanity, 
this  fact  is  of  considerable  interest. 

Roncoroni,*  who  has  made  a  very  thorough  histological  examina- 
tion of  the  cortex  (second  frontal  convolution)  of  33  epileptics  and 
24  criminals,  finds  that  24  of  the  epileptics  showed  an  absence  or 
marked  reduction  in  size  of  the  deep  granular  layer,  whilst  in  10  of 
them  there  were  anomalies  in  the  arrangement  of  the  pyramidal 
cells,  the  main  processes  of  which  were  directed  obliquely  and 
transversely,  instead  of  vertically.  The  pyramidal  cells  were  also 
diminished  in  number  and  of  irregular  development.  He  found 
similar  changes  in  the  granular  and  pyramidal  layer  in  a  majority 
of  the  congenital  criminals,  and  says  that  such  conditions  were  not 
present  in  the  brains  of  any  normal  persons,  nor  in  insane  criminals 
or  epileptics  other  than  those  of  degenerate  type.  Roncoroni,  ex- 
tending his  histological  examination  to  the  brains  of  monkeys, 
dogs,  and  other  of  the  lower  animals,  arrives  at  the  conclusion  that 

*   Roncoroni,  Archiv  di  Psichiat.,  1905,  vol.  xxvi.,  fasc.  4,  5,  and  6. 


78  Pathology 

the  molecular  layer  tends  to  decrease  in  the  higher  evolutionary 
types,  and  he  regards  the  cells  of  this  layer  as  being  concerned  with 
automatic  functions  rather  than  with  the  higher  psychic  processes. 
It  is,  he  considers,  in  agreement  with  this  view  that  in  certain 
human  degenerate  types  the  molecular  layer  is  disproportionately 
large.  Roncoroni's  account,  of  course,  refers  to  the  cells  of  the 
cerebral  cortex.  With  regard  to  fibres,  Kaes  is  of  the  opinion  that 
the  outer  layers  of  tangentially  running  fibres  subserve  higher  pro- 
cesses than  do  those  more  deeply  placed. 

In  cases  of  pronounced  amentia  these  incompletely  developed 
pyramidal  cells  are  found  in  all  regions  of  the  cerebral  cortex. 
There  are,  however,  two  situations  in  which  they  are  most  frequent 
— namely,  the  prefrontal  and,  to  somewhat  less  extent,  the  parietal 
lobes.  It  would  therefore  appear  that  it  is  these  regions  which  are 
chiefly  concerned  in  the  highest  mental  processes,  for  it  is  these 
same  regions  which  show  the  greatest  amount  of  degeneration  in 
dementia.  On  this  point  the  observations  of  J.  S.  Bolton,*  whose 
work  on  the  morbid  histology  of  the  cortex  cerebri  is  probably 
unsurpassed  for  painstaking  care  and  completeness,  are  of  great 
importance.  Bolton  concludes  that  "  the  cellular  elements  through- 
out the  cortex  cerebri  which  are  specially  concerned  in  the  perform- 
ance of  associational  functions  are  those  of  the  pyramidal  layer  -of 
nerve  cells;  the  great  anterior  centre  of  association  of  Flechsig  in 
the  prefrontal  region  is  underdeveloped  on  the  one  hand  in  all 
grades  of  primary  mental  deficiency,  and  on  the  other  hand  under- 
goes primary  a-trophy  pari  passu  with  the  development  of  dementia. 
This  region  of  the  cerebrum  is  therefore  concerned  with  the  per- 
formance of  the  highest  co-ordinating  and  associational  processes 
of  mind." 

It  is  not  improbable  that  the  anatomical  basis  of  psychic  epilepsy 
and  insanity  will  ultimately  be  proved  to  consist  in  an  inherited 
instability,  defective  metabolism,  or  tendency  to  premature  de- 
generation of  these  cells,  the  actual  exciting  cause  of  the  disease 
being  supplied  by  toxins  or  any  of  the  numerous  forms  of  stress 
and  strain  incident  to  modern  life. 

It  is  necessary  to  remark  that  embryonic  cells  similar  to  those  de- 
scribed (neuroblasts)  are  present  in  the  normal  adult  brain,  also 
that  cells  which  appear  to  be  of  perfect  development  may  be  seen 

*  J.  S.  Bolton,  "  Amentia  and  Dementia,"  Journal  of  Mental  Science, 
April,  1905,  et  seq. 


The  Histology   of  Primary  Amentia  79 

in  the  brain  of  the  idiot,  even  of  the  most  pronounced  type;  but 
whereas  in  the  normal  the  number  of  neuroblasts  is  comparatively 
small,  and  the  great  majority  of  the  cells  have  attained  complete 
development,  in  the  latter  the  reverse  is  the  case,  the  bulk  of  the 
cells  being  in  an  immature  condition,  and  many  of  them  also  show- 
ing further  indications  of  defective  function  in  the  presence  of 
considerable  deposits  of  pigment.  Moreover,  the  proportion  of  such 
immature  cells  appears  to  be  directly  related  to  the  degree  of  mental 
deficiency,  and  in  the  milder  degrees  the  microscopical  condition  is 
rather  one  of  paucity  of  cells  and  irregular  arrangement  than  of 
pronounced  imperfection  of  the  individual  cells. 

Nerve  Fibres  of  the  Brain  Cortex. — The  bands  of  tangentially 
coursing  fibres  comprising  the  association  systems  show  a  very 
definite  diminution  in  cases  of  severe  amentia,  so  great,  indeed,  as 
often  to  be  apparent  to  the  naked  eye.  Generally  speaking,  the 
most  marked  alteration  occurs  in  the  fibres  composing  the  outer 
line  of  Baillarger,  next  in  the  super-  and  inter-radial  bundles, 
whilst  the  superficial  tangential  fibres  are  somewhat  less  affected 
(see  Fig.  9,  Plate  I.) .  The  regions  of  the  brain  most  involved  are  the 
frontal  and  parietal  lobes;  in  the  motor  areas  the  change  is  com- 
paratively slight,  and  in  the  occipital  lobes  there  is  often  little 
observable  diminution. 

The  Neuroglia. — -Sclerosis,  or  overgrowth  of  neuroglia,  occurs  in 
some  form  or  other  in  a  considerable  proportion  of  cases.  Dr. 
Wiknarth*  found  it  in  no  less  than  one  quarter  of  the  hundred 
brains  he  examined.  The  cause  of  this  condition  cannot  always 
be  determined ;  in  some  cases  it  is  probably  the  final  result  of  toxic 
or  vascular  lesions ;  in  others  it  would  appear  to  be  a  developmental 
anomaly,  and  to  take  place  in  consequence  of  the  diminished 
multiplication  and  development  of  the  higher  elements — the  nerve 
cells — being,  in  fact,  a  substitution  product.  Sclerosis  may  be 
diffuse  or  circumscribed.  As  an  example  of  diffuse  sclerosis  I  may 
mention  a  brain  which  I  examined  from  an  idiot  dying  at  the  age 
of  twenty  years:  the  whole  organ  was  small,  896  grammes  in  weight, 
and  exceedingly  firm — in  fact,  almost  cartilaginous  in  texture 
throughout.  There  were  no  localized  patches,  but  microscopical 
examination  showed  the  presence  of  a  dense  overgrowth  of  neuro- 
gha  diffused  throughout  all  parts  of  the  brain,  including  the  basal 

*  A.  W.  Wilmarth,  "  Report  on  the  Examination  of  One  Hundred  Brains 
of  Feeble-minded  Children,"  Alienist  and  Neurologist,  October,  1890. 


8o  Pathology- 

ganglia  and  cerebellum.  This  involved  the  white  as  well  as  the 
grey  matter,  and  was  accompanied  by  a  marked  nmnerical  diminu- 
tion as  well  as  irregular  and  incomplete  development  of  the  nerve 
cells  and  their  processes.  There  were  no  signs  of  recent  degenera- 
tion, but  the  pia-arachnoid  membrane  was  somewhat  thickened  in 
places.  The  patient  had  always  been  helpless  and  was  unable  to  do 
anything  for  herself,  but  no  definite  paralysis  was  noticeable.  She 
was  subject  to  constant  choreiform  movements,  but  there  were  no 
convulsions. 

In  other  cases  the  overgrowth  of  neuroglia  takes  the  form  of 
circumscribed  nodules,  which  are  found  in  two  chief  situations. 
The  commonest  site  is  the  grey  matter  of  the  cerebral  cortex,  which 
may  be  occupied  by  a  large  number  of  sharpjy  circumscribed 
sclerotic  areas  varying  in  size  from  a  pin-head  to  a  hazel-nut,  or 
even  larger.  As  generally  seen,  these  are  pale  firm  masses  which 
project  above  the  level  of  the  affected  hemisphere,  they  are  often 
marked  by  a  central  imibilication,  and  the  investing  pid  membrane 
strips  from  them  with  unusual  readiness  and  without  causing  de- 
cortication. This  condition  was  first  described  by  BourneviUe,* 
but  many  examples  have  since  been  recorded  under  the  name  of 
hypertrophic,  nodular,  or  tuberous  sclerosis  or  gliosis..  The  majority 
of  the  patients  have  been  markedly  mentally  deficient  and  have 
suffered  from  epileptic  convulsions.  The  patches  consist  of  a  dense 
interlacement  of  neuroglia  fibres  with  a  varying  proportion  of  cells 
(probably  dependent  upon  their  age),  and  the  lamination  of  the 
adjoining  grey  matter  is  often  considerably  distorted.  The  other 
most  common  site  is  the  floor  of  the  lateral  ventricles,  which  may 
be  studded  with  a  number  of  protuberances  the  size  of  small  peas. 
Microscopical  examination  shows  these  to  consist  of  almost  pure 
glia  tissue,  the  fibres  of  which  are  usually  arrangi^d  in  whorls  around 
the  centre  of  the  nodule.  Finally,  a  dense  band  of  fibrous  neuroglia 
is  occasionally  seen  immediately  under  the  pia  upon  the  surface  of 
the  hemisphere,  closely  applied  to  the  cortex  like  a  cap. 

When  neuroglial  overgrowth  is  present  to  any  considerable  extent, 
it  produces  a  marked  increase  in  the  weight  and  consistence,  and 
often  in  the  size,  of  the  brain.  With  the  lapse  of  time  it  tends  to 
contract,  and  the  relative  age  of  the  cortical  protuberances  may  be 

*  BourneviUe,  "  Recherches  sur  I'ldiotie,"  etc.,  Paris,  1893  ;  see  also 
Joseph  Sailer,  "  Hypertrophic  Nodular  Gliosis,"  Journal  of  Nervous  and  Mental 
Disease,  1898,  p.  402,  in  which  an  account  is  given  of  previously  recorded 
cases;  also  Freud,  "  Infantile  Cerebral  Lahmung,"  p.  136. 


The  Histology  of  Primary  Amentia  8i 

gauged  by  the  size  and  depth  of  their  central  umbiHcation.  It  is 
probably  an  early  stage  of  extensive  neurogliosis  which  gives  rise 
to  the  cranial  enlargement  in  the  hypertrophic  form  of  amentia, 
and  this  condition  is  not  infrequently  called  "  hypertrophy  of  the 
brain."  The  hypertrophy,  however,  concerns  the  supporting,  and 
not  the  true  nervous  tissue. 

Regarding  the  manner  of  production  of  localized  sclerosis  there 
is  much  diversity  of  opinion,  although  the  lesions  suggest  some  kind 
of  vascular  causation.  Jendrassik  and  Marie  point  out  that  the 
first  histological  change  always  takes  place  around  the  small  cor- 
tical arteries,  and  in  a  case  of  Freud's  a  sclerotic  patch  was  con- 
sidered to  be  undoubtedly  the  result  of  an  embolus  of  a  branch  of 
the  middle  cerebral  artery.  Striimpell  sees  in  it  a  possible  after- 
effect of  his  polio-encephalitis  acuta  infantum.  Moreover,  the 
view  of  vascular  origin  derives  support  from  the  fact  that  in  some 
cases  small  collections  of  haematoidin  crystals  have  been  seen, 
evidently  indicative  of  old  haemorrhages.  It  is  therefore  not  im- 
probable that  some,  at  all  events,  of  these  cases  of  tuberous  sclerosis 
have  their  origin  in  one  or  other  of  the  vascular  cerebral  lesions 
occurring  before  birth  or  in  early  infancy,  although  Vogt*  is  of  the 
opinion  that  they  are  to  be  regarded  as  developmental  anomalies. 
The  nerve  ceUs  are  in  many  cases  entirely  absent  from  these  patches, 
but  whether  this  absence  is  the  cause  or  consequence  of  the  gliosis 
is  unknown.  Where  nerve  cells  occur  they  are  rarely  healthy, 
some  being  in  a  state  of  imperfect  development,  whilst  others  are 
atrophied,  distorted,  or  undergoing  chronic  degeneration  (see  Frontis- 
piece, Fig.  5).  The  contiguous  portion  of  the  cortex  is  usually  very 
irregular.  The  nerve  fibres  rarely  show  any  acute  degeneration, 
although  the  tangential  and  association  pathways  of  the  brain  and 
the  efferent  tracts  of  the  cord  are  often  considerably  diminished 
in  size. 

Bloodvessels. — As  a  rule  the  bloodvessels  of  the  brain  in  cases  of 
primary  amentia  show  little  or  no  departure  from  the  normal. 
Occasionally  hyaline  degeneration  is  present;  or  there  is  a  collec- 
tion of  pigment,  similar  to  that  in  the  nerve  cells,  disposed  around 
the  nuclei  of  the  capillary  endothelium.  But  these  conditions  are 
not  constant,  and  I  do  not  think  they  have  any  causal  relationship 
to  the  amentia. 

*  H.  Vogt,  Monatsschr.  f.  Psych,  und  Neurol.,  1908,  Bd.  xxiv. 


82  Pathology 

The  Histology  of  Secondary  Amentia. 

As  has  already  been  stated,  the  difference  between  primary  and 
secondary  amentia  is  that,  whereas  in  the  former  the  full  develop- 
ment of  the  neuroblasts  cannot  take  place  by  reason  of  an  intrinsic 
vital  deficiency,  in  the  latter  their  development  is  arrested  by  some 
external  cause.  This  cause  may  operate  generally,  as  in  cretinism, 
or  its  effect  may  be  local,  as  in  acute  polio-encephalitis  or  the 
vascular  changes  occurring  in  birth  injuries.  In  many  of  these 
cases  the  nerve  cells  present  similar  histological  features  to  those 
in  the  primary  form,  although  it  may  be  possible  to  infer  that  the 
condition  is  secondary  from  the  localized  nature  of  the  agenesis 
and  the  presence  of  softening,  sclerosis,  chronic  inflammation,  or 
other  signs  of  disease  in  an  otherwise  well-developed  bram. 

In  a  considerable  number  of  these  secondary  cases,  however, 
degeneration  of  nerve  cells  subsequently  takes  place,  this  being 
often  accompanied  b}'  more  or  less  dementia.  Where  this  happens, 
the  detection  of  incompletely  developed  ceUs  may  be  exceedingly 
difficult,  just  as  the  original  amentia  may  be  unrecognizable  in  the- 
midst  of  the  dementia.  Such  degeneration  is  a  slow  and  chronic 
process,  there  being  rarely  any  acute  change  discoverable  by 
Marchi's  method  of  staining.  It  begins  as  a  chromatolysis,  with 
accumulation  of  brownish-j^ellow  granular  pigment ;  this  is  followed 
by  a  gradual  atrophy  of  the  axon  and  dendrons,  and  then  by  a 
shrinkage  of  the  cell  body.  Later,  disintegration  of  the  nucleus 
and  nucleolus  occur,  and  this  is  often  followed  by  sclerosis. 

The  cerebral  vessels  sometimes  show  indication  of  this  chronic 
degeneration  in  a  thickening  of  their  walls;  whilst  the  endothelial 
ceUs  of  the  capillaries  and  the  adventitia  of  the  smaller  arteries 
frequently  contain  a  considerable  deposit  of  brownish-yeUow  pig- 
ment (staining  black  with  Marchi's  fluid)  similar  to  that  met  with 
in  the  nerve  cells.  In  cases  of  sclerotic  amentia  indications  of  old 
haemorrhages,  in  the  shape  of  haematoidin  crystals,  are  not  infre- 
quently met  with. 

Morbid  Anatomy. 

Gross    Developmental   Anomalies    and    Pathological    Lesions. — 

Although  the  essential  pathological  condition  underlying  amentia 
is  one  of  imperfect  or  arrested  development  of  the  cortical  cells,  yet 
in  a  considerable  proportion  of  cases  anomalies  of  structure  occur 


Morbid  Anatomy  83 

which  are  sufficiently  gross  to  be  recognizable  by  the  naked  eye. 
These  fall  under  two  headings,  viz. :  (i)  Faults  of  development,  and 
(2)  Lesions  resulting  from  disease.  The  former  occur  in  cases  of 
primary  amentia  only,  and  they  are  obviously  a  more  gross  mani- 
festation of  that  same  germinal  blight  which  has  produced  the 
cellular  imperfection.  The  latter  are  the  after-effects  of  pathological 
processes  which  on  the  one  hand  produce  secondary  amentia,  and 
on  the  other  may  complicate  primary  amentia.  The  following  are 
the  chief  of  these  developmental  anomalies  and  lesions. 

The  brain  of  many  mild  aments,  in  its  size,  weight,  and  general 
appearance,  may  not  be  markedly  different  from  the  normal;  but 
in  the  more  pronounced  degrees  of  mental  deficiency  differences 
are  usually  obvious.  I  have  never  yet  seen  the  brain  of  an  idiot, 
a  low,  or  even  medium -grade,  imbecile,  which  could  be  regarded  as 
normal  upon  careful  naked-eye  examination.  Sometimes  it  is  too 
large,  when  sections  will  show  that  it  contains  an  excess  of  glia 
tissue.  More  often,  however,  it  is  too  small,  and  the  average 
weight  of  the  encephalon  of  the  ament,  even  excluding  cases  of 
microcephaly,  is  several  hundred  grammes  less  than  the  average 
of  the  ordinary  population.  In  many  instances  the  texture  is 
either  abnormally  soft  or  unusually  dense.  In  many  cases,  also, 
there  is  either  a  decided  peculiarity  in  the  whole  configuration,  or 
the  convolutions  are  irregular  and  of  markedly  diminished  com- 
plexity. In  addition  there  are  often  gross  malformations  of  de- 
velopment. In  cases  of  secondary  amentia  these  changes  may  be 
little  marked,  but  they  are  generally  replaced  by  some  obvious  sign 
of  disease. 

Malformations  of  the  central  nervous  system  vary  from  a  trifling 
peculiarity  of  configuration  or  anatomical  arrangement  to  a  com- 
plete suppression  of  important  structures,  such  as  is  seen  in  anen- 
cephalia,  non-development  of  the  medulla,  or  even  absence  of  the 
spinal  cord.  Such  severe  conditions  as  these  are,  of  course,  in- 
compatible with  life,  and  even  if  the  children  were  born  alive,  they 
could  only  survive  a  few  hours.  The  malformations  ordinarily 
seen  in  post-mortem  examinations  of  aments  are  much  less  severe, 
and  are  in  most  instances  situate  in  the  cerebral  hemispheres  or  the 
cerebellum.  This  is  doubtless  owing,  as  Ziegler  says,  to  the  fact 
that  these  parts  "  in  their  development  from  the  primary  cerebral 
vesicles  undergo  the  greatest  amount  of  growth  and  the  most 
important  transformations." 


^4  Pathology 

Most  of  these  anomalies  are  forms  of  localized  hypoplasia,  which 
in  some  instances  may  be  the  result  of  disease  or  vascular  occlusion  ; 
i  n  others,  however,  they  are  due  to  defects  in  the  formative  m.aterial 
of  the  brain.  In  the  cerebral  hemispheres  the  secondary,  or  even 
the  primary,  fissures  may  be  imperfectly  formed,  there  may  be 
agenesis  of  a  lobule  or  a  whole  group  of  convolutions,  or  there  may 
be  a  general  undergrowth  of  the  whole  of  one  hemisphere.  This 
latter  condition  is  called  cerebral  hemiatrophy,  and  the  affected 
hemisphere  may  weigh  from  200  to  300  grammes  less  than  the 
opposite  one.  In  a  considerable  proportion  of  cases  a  condition  of 
microgyria  is  seen,  in  which  a  group  of  contiguous  convolutions  are 
represented  by  thin  membranous  folds,  almost  devoid  of  nervous 
tissue,  and  somewhat  resembling  the  conduplication  seen  in  the 
unexpanded  petals  of  a  flower-bud.  Porencephaly"^  is  another  not 
uncommon  pathological  finding,  and  is  due  to  a  non-development 
of  the  central  convolutions  around  the  inferior  extremity  of  the 
Sylvian  fissure^  As  a  consequence,  a  deep  funnel-shaped  cleft  is 
produced  which  extends  down  to,  and  communicates  with,  the 
cavity  of  the  lateral  ventricle.  This  cleft  is  lined  by  the  pia  and 
bridged  over  by  the  arachnoid  membrane,  the  contained  space 
being  filled  with  cerebro-spinal  fluid.  A  somewhat  similar  depres- 
sion may  arise  as  the  result  of  disease  of  the  brain  matter  external 
to  the  lateral  ventricle,  which  in  many  instances  is  brought'  about 
by  a  lesion  of  the  Sylvian  artery.  This  condition,  as  well  as  other 
circumscribed  and  cystic  depressions  of  the  brain  surface,  or  even 
severe  hemiatrophy,  are  often  described  as  pseudo-porencephaly . 

Other  more  uncommon  developmental  anomalies  of  the  en- 
cephalon  consist  of  malformations  of  the  basal  ganglia,  deficiency 
or  absence  of  the  corpus  callosum,  fornix,  optic  thalami,  corpora 
quadrigemina,  and  corpora  mammillaria.  Arndt  and  Sklarek,-|-  in 
a  post-mortem  examination  on  an  imbecile  girl  aged  sixteen  years 
who  died  in  the  Dalldorf  Asylum,  found  that,  in  addition  to  de- 
ficiency of  the  corpus  callosum,  there  were  abnormalities  of  the 
pillars  and  commissure  of  the  fornix,  of  the  gyrus  fornicatus  and 
fibres  of  the  anterior  commissure,  as  well  as  absence  of  the  psalte- 
rium  and  septimi  pellucidum.  They  quote  twenty-nine  recorded 
cases  of  deficiency  of  the  corpus  callosum,  most  of  them  accompanied 

*  See  Kundrat,  "  Die  Porencephalie,"  Graz,  1SS2  ;  also  Audry,  "  Las 
Porencephalies,"  Revue  de  M&decine,  June,  iSSS. 

■f  Arndt  and  Sklarek,  Archiv  f.  Psychiat.,  Bd.  xxxvii.,  Heft  3. 


Morbid  Anatomy  85 

by  other  defects  of  brain  structure,  and  the  majority  of  the  patients 
being  idiots. 

Anomalies  of  the  cerebellum  consist  chiefly  of  a  general  hypo- 
plasia, which  occurs  with  considerable  frequency  in  the  Mongo- 
lian type  of  amentia,  as  well  as  of  various  forms  of  localized  agenesis 
similar  to  those  met  with  in  the  cerebrum. 

It  is  to  be  remarked  that  such  lesions,  whether  due  to  faults  of 
development  or  to  disease,  are  very  likely  to  interfere  with  the 
growth,  or  to  cause  degeneration,  of  other  portions  of  the  nervous 
system  with  which  the  affected  areas  are  functionally  related. 
Thus,  in  lesions  of  the  motor  cortex  there  is  sclerosis  of  the  corre- 
sponding efferent  tract  throughout  the  pons,  medulla,  and  cord, 
and  corresponding  to  this  there  is  often  a  numerical  diminution  of 
the  anterior  horn  cells  of  the  cervical  and  lumbar  enlargements. 
Lesions  of  the  basal  ganglia  may  give  rise  to  secondary  changes  in 
the  cerebellum  and  its  superior  peduncle  of  the  opposite  side,  also 
in  the  fillet  and  interolivary  layer  of  the  pons  and  medulla  of  the 
same  side.  Lesions  of  the  motor  cortex  may  even  interfere  with 
the  development  of  the  great  association  centres.  In  examining 
anomalies  of  the  nervous  system,  it  is  thus  not  always  easy  to 
disentangle  those  lesions  which  are  primary  from  those  which  are 
in  this  way  secondarily  produced. 

Hydrocephalus  is  a  not  uncommon  accompaniment  of  both  the 
primary  and  secondary  forms  of  amentia ;  it  occurs  in  two  varieties. 
In  one  variety  the  excess  of  cerebro-spinal  fluid  occurs  within  the 
ventricles,  and  is  then  known  as  "  internal  hydrocephalus."  In 
the  other  it  is  situated  external  to  the  surface  of  the  brain,  and  is 
then  known  as  "  meningeal  hydrocephalus  "  or  "  hydrocephalus 
ex  vacuo." 

The  cause  of  Internal  Hydrocephalus  is  often  obscure.  Some 
cases  date  from  early  embryonic  life;  in  others  the  condition  first 
appears  in  early  childhood.  Both  syphilitic  and  tubercular  lesions 
have  been  found,  and  in  other  cases  chronic  thickenings  of  the 
choroid  plexuses  are  seen.  It  is  probable  that  the  affection  in 
many  instances  depends  on  closure  of  the  communications  between 
the  cavities  of  the  ventricles  and  the  subarachnoid  space  in  the 
transverse  fissure ;  but  as  to  the  causes  bringing  about  this  closure 
we  know  very  little.  On  the  other  hand,  there  is  no  doubt  that  in 
some  instances  internal  hydrocephalus  may  be  secondary  and  com- 
pensatory to  non-development  of  the  brain  tissue.    This  is  probably 


86  Pathology 

so  in  those  cases  where  it  is  confined  to  one  ventricle,  the  substance 
of  the  corresponding  hemisphere  being  thin  and  undeveloped;  also 
in  those  cases  in  which  it  accompanies  a  general  hypoplasia  of  the 
cerebrum,  such  as  occurs  in  microcephaly.  Distension  of  the  ven- 
tricles, even  to  a  considerable  extent,  is  a  not  very  uncommon 
finding  in  microcephalic  amentia. 

External  Hydrocephalus  is  always  compensatory  to  disease  or 
non-development  of  the  cerebral  tissue.  The  excess  of  fluid  is 
situate  in  the  subarachnoid  space,  and  always  occurs  in  the  vicinity 
■of  the  local  defects.  In  cases  of  general  atrophy  of  the  convolutions 
due  to  dementia,  the  dilated  sulci  are  filled  with  pale,  clear  cerebro- 
spinal fluid.  In  conditions  of  localized  disease,  or  agenesis,  on  the 
other  hand,  the  fluid  is  confined  to  form  a  cyst.  This  is  particularly 
well  seen  in  some  cases  of  pseudo-porencephaly.  It  may  happen 
for  internal  and  external  hydrocephalus  to  be  present  in  the  same 
brain. 

Encephalitis  and  Meningo- Encephalitis. — These  conditions  are 
always  indicative  of  a  previous  disease  of  the  brain.  They  are 
therefore  commoner  in,  but  not  restricted  to,  the  secondary  form 
of  amentia.  The  cause  is  one  or  other  of  the  toxic  or  vascular 
lesions  which  have  already  been  described  in  the  chapter  on  Causa- 
tion; but  they  have  no  constant  relationship  to  any  particular  one 
of  them.  ■  Encephalitis  may  result  alike  from  cortical  haemorrhages, 
thrombosis  of  the  meningeal  veins  due  to  asphyxia,  or  a  poisoning 
of  the  cortical  ceUs.  Sachs*  considers  chronic  meningo-encephal- 
itis  to  be  a  common  result  of  the  meningeal  haemorrhages  occurring 
during  birth,  but  Freud  is  of  opinion  that  these  cases  do  not  com- 
monly terminate  in  a  chronic  inflammatory  process  between  the 
membrane  and  underlying  brain  surface. 

There  can  be  no  doubt  that  in  the  majority  of  cases  of  amentia, 
which  are  due  to,  or  accompanied  by,  "  birth  paralysis  "  (Little's 
disease),  meningeal  haemorrhage  is  present,  although  in  occasional 
instances  the  haemorrhage  may  be  within  the  brain  cortex.  Where 
the  bleeding  is  from  the  membrane,  the  clot  is  usually  between  the 
pia  and  the  brain  surface,  and  it  may  be  situated  over  the  vertex 
or  at  the  base.  Holtf  says  that  the  posterior  part  of  the  base  is 
much  the  more  frequent  site,  and  that  a  diffuse  haemorrhage  is. 

*  Sachs,  "  A  Treatise  on  the  Nervous  Diseases  of  Children,"  New  York, 
1895. 

f   R.  Holt,  "  Diseases  of  Infancy." 


Morbid  Anatomy  87 

commoner  than  is  a  single  circumscribed  clot.  He  further  states 
that,  whilst  the  quantity  of  blood  extravasated  varies  from  one 
drachm  to  four  ounces,  it  is  usually  about  one  ounce. 

However  produced,  inflammation  of  the  cerebral  cortex  usually 
leads  to  marked  histological  changes.  In  most  cases  there  is  con- 
siderable distortion  of  all  the  affected  tissue,  so  that  the  lamination 
is  exceedingly  confused  and  irregular.  In  many  cases  the  normal 
layers  are  almost  indistinguishable,  and  the  cortex  consists  of  a 
haphazard  collection  of  various-sized  cells.  Associated  with  this 
there  may  be  a  clear,  pale  layer  devoid  of  cells  at  a  little  distance 
below  the  brain  surface.  In  some  cases  areas  of  sclerosis  are  found, 
or  there  is  a  more  diffuse  proliferation  of  the  neuroglia;  in  other 
cases  there  are  small  localized  softenings.  The  vessels  are  often 
numerous  and  the  perivascular  spaces  dilated;  whilst  if  the  lesion 
occurs  in  the  motor  region,  there  is  usually  a  chronic  degeneration 
of  the  efferent  tract,  which  may  be  traced  through  the  medulla  and 
cord.  The  term  "  agenesis  corticalis  "  has  been  applied  by  Sachs 
to  this  condition  where  of  intra-uterine  origin. 

In  meningo-encephalitis  the  pia-arachnoid  is  found  to  be  con- 
siderably thickened,  opaque,  unduly  vascular,  and  firmly  adherent 
to  the  underlying  brain  tissue,  from  which  it  cannot  be  detached 
without  causing  decortication.  In  some  cases  the  softening  and 
disintegration  of  the  brain  substance  is  definitely  circumscribed; 
the  space  thus  forrned  is  filled  with  cerebro-spinal  fluid,  and  bridged 
over  by  the  investing  membrane,  forming  a  so-called  arachnoid 
cyst. 

In  a  certain  number  of  cases  of  amentia,  even  where  there  are 
none  of  these  gross  lesions,  dementia  supervenes.  There  is  then 
usually  found  more  or  less  atrophy  of  the  convolutions,  with  con- 
siderable excess  of  fluid  in  the  widened  sulci,  and  in  these  cases  the 
membranes  are  also  thickened  and  opaque;  but  the  pia-arachnoid 
strips  with  unusual  readiness,  unlike  the  adhesion  in  chronic 
meningo-encephalitis.  The  dura  mater  is  sometimes  firmly  at- 
tached to  the  bone,  and  very  occasionally  osseous  plates  and 
subdural  false  membranes  have  been  found.  Apart  from  these 
conditions  of  disease  or  dementia,  the  membranes  in  persons  suffer- 
ing from  amentia  rarely  show  any  pathological  change. 

The  Skull. — In  most  cases  of  primary  amentia  the  skull  is  thicker 
and  denser  than  normal,  the  diploe  often  being  non-existent.  In 
some  instances  the  sutures  are  found  firmly  and  prematurely  united, 


88  Pathology 

from  which  arose  the  erroneous  notion  that  premature  synostosis 
was  a  cause  of  idiocy.  Where  extensive  cerebral  hemiatrophy 
exists,  whether  from  disease  or  congenital  anomaly  of  development, 
there  may  be  considerable  asymmetry  of  the  cranium  as  seen  from 
the  outside ;  but  it  often  enough  happens  that  no  external  malforma- 
tion is  noticeable  in  this  condition,  the  deficiency  being  associated 
with  a  considerable  enlargement  of  the  inner  table  of  the  skull  only. 
In  some  of  these  cases  there  is  no  bony  overgrowth  at  all,  the  space 
being  merely  filled  with  an  excess  of  cerebro-spinal  fluid.  The 
various  anomalies  of  external  configuration  will  be  described  in 
subsequent  chapters. 


CHAPTER  V 

CLASSIFICATION 

We  have  seen  that  there  are  two  fundamentally  difleient  forms  of 
amentia ;  there  are  also  innumerable  degrees  ;  and  it  is  convenient 
to  describe  certain  distinctive  clinical  varieties.  Unfortunately,  the 
neglect  of  some  authors  to  make  these  distinctions  clear  has  had 
the  effect  of  unnecessarily  complicating  the  classification  of  mental 
deficiency,  which  is  in  any  case  a  task  of  sufficient  difficulty. 

The  Forms  of  Amentia. 

The  great  majority  of  aments  (probably  between  85  and  90  per 
cent.)  are  the  products  of  a  defective  germ  plasm.  In  consequence 
of  this  blight,  neuronic  development  is  irregular  and  imperfect,  and 
a  condition  of  primary  amentia  ensues. 

In  from  10  to  15  per  cent,  of  cases  there  is  no  morbid  inheritance 
and  no  inherent  inability  to  develop,  but  the  growth  of  a  portion 
of  the  brain  is  interfered  with,  or  arrested  by,  disease  or  other  ad- 
verse environment.    This  condition  may  be  called  secondary  amentia. 

At  first  sight  these  terms  may  appear  to  be  synonymous  with 
the  older  ones — "  congenital  "  and  "  acquired."  They  are  not  so, 
however,  for  so-called  "  congenital  "  (existing  at  birth)  amentia 
may  in  reality  be  secondary  and  due  to  a  factor  of  the  environment 
operating  in  utero  ;  whilst  amentia  which  does  not  become  manifest 
until  late  in  childhood,  and  which  would  be  called  "  acquired," 
may  really  be  the  result  of  a  primary  imperfection  of  the  germ  cell. 
I  think,  therefore,  that  the  terms  "  primary  "  and  "  secondary  " 
are  not  only  more  accurate,  but  materiaUj^  assist  our  conception  of 
the  real  nature  of  the  condition  present.  As  will  presently  be  seen, 
these  two  forms  are  not  only  essentially  different  in  their  etiology, 
but  they  often  present  totally  distinct  pathological,  psychological, 
and  physiognomical  features. 


90  Classification 

But  whilst  the  majority  of  cases  of  amentia  are  readily  referable 
to  one  or  other  of  these  two  chief  forms,  there  are  a  few  which  seem 
to  be  intermediate  between  them.  In  these  morbid  inheritance  is 
present,  but  the  brothers  and  sisters  of  the  patient  are  seemingly 
healthy,  and  the  patient  himself  has  seemed  to  be  well  in  body  and 
mind  until  the  advent  of  some  "  illness,"  "  fright,"  or  "  fall,"  etc., 
in  the  early  months  or  years  of  life.  These  cases  have  been  called 
developmental,  and  the  term  is  in  some  respects  very  convenient. 
But  inquiries  usually  show  that  the  exciting  factor  is  of  a  com- 
paratively trivial  nature,  quite  disproportionate  to  the  mental 
disability  which  follows,  and  such  as  would  be  incapable  of  damag- 
ing the  nervous  system  of  a  healthy  child.  There  can  be  no  doubt, 
therefore,  that  in  such  cases  the  inherited  condition  of  the  nervous 
system  is  a  factor  of  the  utmost  moment,  and  perhaps  the  term 
delayed  primary  amentia  would  best  define  the  class. 

The  Degrees  of  Amentia. 

Amentia  varies  greatly  in  its  degree,  irrespective  of  form  or 
clinical  variety.  In  some  cases  the  defect  is  but  slight;  in  others 
it  is  so  severe  that  mind  can  hardly  be  said  to  be  present  at  all. 
Between  these  two  extremes  there  is  every  gradation;  and  since 
the  differences  are  of  quantity  rather  than  quality,  of  degree  and 
not  kind,  any  classification  must  be  an  arbitrary  one.  Esquirol 
suggested  the  faculty  of  speech  as  a  dividing-line;  but  this  is  un- 
satisfactory, as  there  are  quite  mild  aments  who  cannot  speak. 
SoUier*  proposed  the  faculty  of  attention ;  but  this  is  also  far  from 
being  a  reliable  criterion  as  to  the  amount  of  defect.  In  fact,  there 
is  no  one  psychological  faculty  or  function  upon  the  presence  or 
absence  of  which  we  can  rely  as  a  means  of  defining  the  degree  of 
amentia. 

Nevertheless,  it  is  essential,  both  for  purposes  of  description  and 
administration,  that  a  division  should  be  made,  and  this,  on  the 
whole,  is  best  done  by  means  of  three  terms  which  have  long  been 
in  use — namely,  FeeUe-mindedness,  Imbecility,  and  Idiocy.  To  one 
or  other  of  these  degrees  we  may  relegate  all  aments,  although  it 
is  to  be  remembered  that  the  boundary-lines  are  by  no  means 
distinct,  and  that  the  one  gradually  merges  into  the  other.  We 
may,  indeed,  if  necessary,  further  subdivide  each  of  them  into  three 
*  P.  SoUier,  "  Psychologie  de  I'ldiot  et  de  I'lmbecile,"  Paris,  1S91. 


The  Degrees  of  Amentia  91 

others,  and  thus  describe  high-,  medium-,  and  low-grade  idiocy, 
imbecility,  and  feeble-mindedness  respectively. 

A  concise  definition  of  these  three  terms  is  impossible,  for  the 
reason  that  they  are  used  with  reference  to  the  amount  of  general 
intellectual  capacity  present;  but  the  chief  characteristics  of  each 
are  summarized  in  the  following  descriptions.  A  definition  of 
amentia  has  already  been  given  on  p.  8. 

Feeble-mindedness  (High-Grade  Amentia). — This  is  the  mildest 
grade  of  mental  defect.  The  members  of  the  class  are  usually  able- 
to  make  tolerable  progress  in  elementary  school  knowledge;  they 
can  read,  write,  do  simple  sums,  and  learn  certain  elementary  facts 
of  geography,  history,  and  the  like.  They  can  engage  in  routine 
work  of  a  simple  character  with  little  or  no  supervision,  and  at 
times  with  a  pertinacity  and  dexterity  which  is  surprising.  They 
can  earn  their  living  if  provided  with  an  occupation  suited  to  their 
capacity  and  treated  with  a  little  indulgence  and  some  oversight. 
But  they  cannot  lay  out  the  money  so  earned  so  as  to  provide  for 
themselves;  they  are  lacking  in  the  capacity  to  deal  with  circum- 
stances out  of  their  routine;  they  cannot  make  definite  plans  for 
their  future ;  and  they  cannot  co-ordinate  their  conduct  in  such  a 
way  as  to  enable  them  to  maintain  an  existence  independently  of 
some  outside  supervision. 

The  Royal  College  of  Physicians  of  London  defined  the  feeble- 
minded person  as  "  one  who  is  capable  of  earning  a  living  under 
favourable  circumstances,  but  is  incapable,  from  mental  defect 
existing  from  birth,  or  from  an  early  age,  {a)  of  competing  on  equal 
terms  with  his  normal  fellows;  or  (&)  of  managing  himself  and  his 
affairs  with  ordinary  prudence."  This  definition  was  adopted  by 
the  English  Royal  Commission  and  utilized  as  the  basis  of  classifica- 
tion in  their  inquiries;  but  it  has  been  altered  in  the  Mental  De- 
ficiency Act  of  1913,  and  the  definition  of  this  class,  according  to 
the  Law  of  England,  is  now  as  follows: 

"  Persons  in  whose  case  there  exists  from  birth  or  from  an  early  age 
mental  defectiveness  not  amounting  to  imbecility,  yet  so  pronounced 
tJiat  they  require  care,  supervision,  and  control  for  their  own  protection 
or  for  the  protection  of  others,  or,  in  the  case  of  children,  that  they,  by 
reason  of  such  defectiveness,  appear  to  he  permanently  incapable  of 
receiving  proper  benefit  from  the  instruction  in  ordinary  schools." 

Feeble-minded  persons  under  the  age  of  sixteen  years  come 
within  the  jurisdiction  of  the  education  authority  by  reason  of  a 


92  Classification 

special  Act  of  Parliament  (Defective  and  Epileptic.  Children  Act, 
1899).  On  account  of  this  Act  they  are  commonly  designated 
mentally  defective  children,  and  they  are  defined  in  this  Act  as  "  those 
children  who,  not  being  imbecile,  and  not  being  merely  dull  and  back- 
ward, are,  by  reason  of  mental  defect,  incapable  of  receiving  proper 
benefit  from-  the  instruction  in  the  ordinary  public  elementary  schools, 
but  are  not  incapable  by  reason  of  such  defect  of  receiving  benefit  in 
such  special  classes  or  schools  as  are  in  this  Act  mentioned.'-' 

It  should  be  remarked  that  in  America  the  term  "  feeble-minded- 
ness  "  is  not  thus  used  specifically  of  the  mildest  degree  of  amentia, 
but  is  applied  generically  to  the  whole  order  of  amentia,  thus  being 
synonymous  with  the  English  term  "  mental  deficiency."  In  that 
country  the  feeble-minded  grade  are  designated  morons  (from  the 
Greek  word  meaning  "  a  fool — a  person  mainly  lacking  in  judgment 
and  good  sense  ") .  This  term  was  first  suggested  by  Dr.  H.  Goddard, 
and  has  much  to  recommend  it,  and  it  is  now  not  infrequently 
applied  to  the  feeble-minded  in  England.  There  has  also  been  an 
attempt  in  this  country  to  apply  the  term  "  feeble-mindedness  "  in  a 
generic  sense  and  to  include  all  grades  of  defect  in  this  euphemistic 
description,  the  mildest  grade  of  all  (the  feeble-minded)  being 
termed  "  mental  defectives."  The  attempt  has  not  met  with  much 
success,  however,  and  since  "  feeble-mindedness  "  is  in  itself  a  more 
specific  term  than  is  "  mental  defect,"  I  think  it  is  decidedly  better 
to  restrict  its  use  to  the  mildest  degree,  and  to  use  "  mental  defect." 
as  synonymous  with  amentia. 

The  capabilities  of  the  feeble-minded,  or  morons,  are  so  varied 
that  for  administrative  purposes  it  is  often  a  matter  of  practical 
convenience  to  subdivide  them  into  three  grades.  I  am  in. com- 
plete agreement  with  those  suggested  by  Dr.  Goddard,*  as  follows: 

1.  High  Grade. — Can  do  fairly  complicated  work  with  only 
occasional  or  no  supervision;  can  run  simple  machinery;  can  take 
care  of  animals;  only  unable  to  plan. 

2.  Middle  Grade. — Can  do  routine  institution  work.. 

3.  Low  Grade. — Can  run  errands,  do  light  work,  make  beds, 
scrub,  care  for  rooms  if  there  is  no  great  complexity  of  furniture. 

Imbecility  (Medium-Grade  Amentia). — The  imbeciles  are  char- 
acterized by  a  more  pronounced  degree  of  defect.  They  can  usually 
read  and  spell  simple  words  of  one  syllable,  can  count  upon  their 

*  H.  Goddard,  Twenty-Second  Annual  Report  of  the  New  Jersey  Training 
School  for  Feeble-minded,  1910,  pp.  136,  137. 


The  Degrees  of  Amentia  93 

fingers,  can  tell  their  name,  say  whether  it  is  morning  or  afternoon, 
winter  or  summer;  they  recognize  and  name  common  objects,  and 
can  tell  for  what  they  are  used,  but  they  cannot  give  a  description 
of  them.  The  higher  members  can  assist  in  fetching  and  carrying, 
in  helping  to  clean  and  scrub,  and  some  of  them  can  perform  short 
tasks  unaided  if  these  are  simple  and  they  are  told  exactly  what  to 
do.  They  can  also  dress,  wash,  and  feed  themselves  under  super -. 
vision.  In  the  medium  grade  the  capacity  for  useful  employment- 
is  less,  and  practically  nothing  can  be  done  without  oversight ; 
whilst  the  lowest  grade  approximate  to  the  idiots,  and  are  incapable 
of  any  useful  work.  All  of  them  are  capable  of  guarding  themselves 
against  the  common  physical  dangers  which  threaten  existence — 
for  instance,  they  will  not  deliberately  walk  into  a  pond  or  put  their 
hands  in  the  fire,  and  they  will  get  out  of  the  way  of  a  motor-car. 
But  none  of  them  are  capable  of  performing  work  which  will  pay 
for  their  keep. 

In  a  former  edition  of  this  book  the  imbecile  was  defined  as 
"  one  who,  by  reason  of  mental  defect  existing  from  birth,  or  from 
an  early  age,  is  incapable  of  earning  his  own  living,  but  is  capable 
of  guarding  himself  against  common  physical  dangers,"  and  I  think 
that,  on  the  whole,  that  is  probably  the  best  concise  definition  of 
this  degree  which  can  be  given ;  but  the  Mental  Deficiency  Act  now 
defines  imbeciles  as  "persons  in  whose  case  there  exists  from  birth  or- 
from  an  early  age  mental  defectiveness  not  amounting  to  idiocy,  yet 
so  pronounced  that  they  are  incapable  of  managing  themselv&s  or  their 
affairs,  or,  in  the  case  of  children,  of  being  taught  to  do  so.". 

I  must  admit  that  I  fail  to  see  that  this  definition  differentiates 
in  any  way  between  the  imbecile  and  the  feeble-minded  person; 
however,  it  has  now  received  the  sanction  of  Parliament,  and  must 
be  used  for  purposes  of  legal  certification. 

Idiocy  (Low-Grade  Amentia). — This  is  the  most  pronounced 
degree  of  mental  defect,  and  I  regard  its  essential  characteristic  as 
an  inability  to  understand  and  avoid  the  common  physical  dangers 
which  threaten  existence.  In  addition,  idiots  are  incapable  of 
performing  any  useful  task,  they  cannot  wash  or  dress  themselves, 
they  cannot  form  sentences,  and  the  majority  of  them  cannot 
articulate  beyond  a  few  monosyllables.  I  divide  them  into  two 
grades — (i)  Partial  or  incomplete,  in  which  the  primitive  feelings  of 
hunger  and  thirst  are  present,  and  the  patients  may  be  trained  to 
some  extent  in  habits  of  cleanliness  and  self-help,  and  (2)  complete, 


94  Classification 

absolute,  and  profound,  in  which  there  is  a  lack  of  the  fundamental 
organic  instincts,  no  power  of  attention,  and  a  complete  incapacity 
for  being  taught. 

The  definition  formerly  given  of  this  grade,  and  which  is  now 
adopted  in  the  Mental  Deficiency  Act,  defines  idiots  as  "  persons  so 
deeply  defective  in  mind  from  birth,  or  from  an  early  age,  as  to  be  unable 
to  guard  themselves  against  common  physical  dangers." 

It  may  be  remarked  that  the  three  terms  "  idiot,"  "  imbecile," 
and  ' '  feeble-minded  ' '  are  not  infrequently  applied  to  various  grades 
of  (dementia,  particularly  the  dotage  of  old  age,  just  as  "  mental 
deficiency  "  is  sometimes  used  generally  for  that  condition.  Since 
this  practice  is  likely  to  lead  to  considerable  confusion,  it  is  to  be 
deprecated. 

In  addition  to  the  above  definitions  it  may  perhaps  be  well  in 
this  place  to  include  that  of  moral  imbecility.  The  Mental  Defi- 
ciency Act  defines  moral  imbeciles  as  "persons  who  from  an  early 
age  display  some  permanent  mental  defect  coupled  with  strong  vicipus 
or  criminal  propensities  on  which  punishment  has  had  little  or  no 
deterrent  effect."  I  shall  deal  with  this  class  more  fully  in  a  later 
chapter,  but  it  may  here  be  pointed  out  that  according  to  this 
definition  moral  imbecility  is  simply  amentia,  plus  a  propensity 

to  vice.* 

The  Varieties  of  Amentia. 

If  a  sufficiently  large  series  of  aments  be  examined,  it  will  be 
found  that,  quite  irrespective  of  their  degree  of  defett,  they  may  be 
divided  into  certain  groups  dependent  upon  the  presence  of  char- 
acters in  common.  These  groups  constitute  the  clinical  varieties  of 
amentia.  It  must  be  admitted  that  the  division  of  the  natural 
order  of  amentia  into  these  clinical  groups  has  hitherto  been  a 
somewhat  arbitrary  process,  since  authors  have  been  by  no  means 
agreed  as  to  what  particular  characteristics  should  be  made  use  of 
for  this  purpose.  There  has  been,  in  fact,  a  confusion  somewhat 
similar  to  that  existing  amongst  biologists  as  to  the  characters 
which  should  denote  a  "  species."  Considering  that  it  is  only 
recently  that  the  subject  has  been  scientifically  studied,  this  is  not 
to  be  wondered  at,  and  for  some  time  any  classification  of  this  kind 
must  be  of  a  provisional  nature,  but  I  think  that  the  fourteen 
varieties  enumerated  in  the  table  on  p.  97  include  all  those  known 

*  See  Table  in  Appendix  for  the  English,  American,  French,  and  German 
synonyms  for  these  terms. 


The  Varieties  of  Amentia  95 

at  the  present  time  which  agree  in  the  common  possession  of  char- 
acters of  sufficient  importance  to  entitle  them  to  rank  as  distinct 
clinical  or  pathological  entities.  Some  of  these  fall  into  the  primary, 
and  others  into  the  secondary,  group  of  amentia,  and  we  may  brief!}' 
refer  to  these  groups  separately. 

The  Clinical  Varieties  of  Primary  Amentia., 

The  majority  of  persons  suffering  from  primary  amentia  present^ 
no  special  distinguishing  features  other  than  the  anatomical  and 
physiological  anomalies  common  to  aments  in  general;  they  may 
therefore  be  termed  simple  aments,  and  they  correspond  to  the 
"  genetous  "*  group  of  Ireland.  In  others,  however,  the  imper- 
fection of  development,  for  some  reason  or  other,  has  taken  a 
particular  form,  and  thereby  produced  marked  cranial  or  physiog- 
nomical peculiarities;  since  these  are  often  associated  with  special 
mental  characteristics,  we  are  justified  in  alluding  to  them  as 
separate  varieties.  The  most  important  of  these  are  the  Micro- 
cephalics and  the  Mongolians.] 

In  a  not  inconsiderable  number  of  primary  aments  (particularly 
of  the  simple  variety)  there  exist  severe  gross  lesions.  In  many 
cases  these  are  only  revealed  after  death,  but  it  occasionally  happens 
that  they  are  so  pronounced  during  life  as  to  justify  the  use  of  them 
as  a  further  means  of  classification.  Accordingly,  we  may  describe 
sclerotic,  porencephalic,  and  (occasionally)  hydrocephalic  subvarieties 
of  primary  amentia.  Epilepsy  and  paralysis  are  such  common 
complications  of  all  these  cases  that  their  presence  can  hardly  be 
said  to  constitute  separate  varieties. 

The  Clinical  Varieties  of  Secondary  Amentia. 

Cases  of  secondary  amentia  are  divisible  into  two  main  classes — 
(i)  Those  in  which  the  arrested  development  is  the  result  of  a 
gross  cerebral  lesion-;  (2)  those  in  which  it  is  due  to  some  external 
factor  adversely  influencing  cerebral  nutrition. 

Class  I.  Amentia  due  to  Cerebral  Lesions. — Disease  of  the  brain 
may  be  due  to  circulating  toxins  or  mechanical  (generally  vascular) 

*  This  term  is  open  to  the  objection  that  all  primary  aments  may  in  reality 
be  called  "  genetous." 

t  Negroid,  Grecian,  Egyptian,  and  American  Indian  types  have  also  been 
described ;  but  as  these  are  rare,  and  their  characteristics  by  no  means  definite, 
they  will  not  be  alluded  to  further. 


96  Classification 

causes.  These  may  arise  from  many  different  factors  which  have 
aheady  been  specified,  and  which  will  be  dealt  with  more  fully  in 
Chapter  XIII.  Since  the  lesions  themselves  present  different 
anatomical  features,  there  are  usually  produced  more  or  less  well- 
marked  clinical  subvarieties,  which  may  be  enumerated  as  follows : 

1.  Syphilitic. 

2.  Amaurotic- 

3.  Hydrocephalic^ 

4.  Porencephalic,  c 

5.  Sclerotic  ■ 

6.  Paralytic  ■ 

7.  Other  toxic,  inflammatory  and  vascular. 

Class  2.  Amentia  due  to  Defective  Cerebral  Nutrition. — ^The  nutri- 
tion of  the  brain  may  suffer  (i)  in  consequence  of  qualitative  ot 
quantitative  anomalies  of  the  blood-supply,  or  (2)  as  a  results  of 
the  deprivation  of  nervous  stimuli  from  without.  Cretinism  is  the 
best-known  and  most  important  example  of  the  former,  although 
possibly  other  abnormal  states  of  the  blood  may  so  act.  The 
absence  of  the  nervous  stimuli  necessary  to  development  produces 
amentia  from  isolation  or  sense  deprivation.  The  clinical  varieties 
of  this  class  are  therefore  enumerated  as — 

1.  Epileptic  amentia.. 

2.  Cretinism. 

3.  Amentia  due  to  malnutrition.  ■ 

4.  Amentia  due  to  isolation  or  sense  deprivation. 

A  few  words  of  explanation  are  required  concerning  the  posi- 
tion given  to  epileptic  amentia.  Epilepsy  frequently  occurs 
in  primary  amentia,  but  it  is  then  to  be  regarded  as  a  com- 
plication, from  which  any  of  these  varieties  may  suffer,  rather  than 
a  variety  in  itself.  On  the  other  hand,  cases  occur  in  which  there 
has  been  no  indication  of  mental  defect  prior  to  the  onset  of  the 
convulsions,  in  which,  in  fact,  the  amentia  is  clearly  induced  by 
the  convulsions;  it  is  therefore  secondary,  and  it  is  to  this  class 
that  I  restrict  the  term  "  epileptic  amentia."  It  is  true  that  such 
patients  are  often  the  victims  of  a  psychopathic  inheritance;  but 
it  seems  tolerably  certain  that  were  there  no  epilepsy  there  would 
be  no  amentia,  and  epileptic  amentia  so  produced  is  a  well-defined 
clinical  entity.  Although  little  at  present  is  known  as  to  the  cause 
of  epilepsy,  the  trend  of  recent  research  is  to  attribute  it  to  some 
innate  or  acquired  disorder  of  metabolism,  and  hence  this  variety 


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98  Classification 

of  amentia  is  provisionally  included  in  the  group  due  to  defective 
cerebral  nutrition. 

Some  years  ago  I  published  a  scheme  devised  to  show  the  rela- 
tionship existing  between  the  etiological  factors,  pathological  con- 
ditions, and  clinical  varieties  of  amentia.*  It  is  given  in  a  modified 
form  on  p.  97,  It  will,  of  course,  readily  be  understood  that  any 
scheme  of  classification  must  at  present  be  provisional,  and  the  only 
merit  I  claim  for  this  table  is  that  it  attempts  to  show  at  one  view 
this  relationship  as  far  as  it  is  at  present  known. 

*  "Amentia:  its  Causes,  Classification,  and  Patliology,"  Archives  of 
Neurology,  vol.  ii.,  1903. 


CHAPTER  VI 
NEURO-PHYSIOLOGY  AND  PSYCHOLOGY 

Amentia  has  been  defined  as  an  imperfection  of  mind  of  such  a 
nature  that  the  person  affected  is  incapable  of  so  adjusting  his 
conduct  as  to  maintain  existence  without  external  support.  But 
ability  to  regulate  conduct  and  maintain  existence  is  no  single 
psychological  function;  it  necessitates  the  presence,  and  the  har- 
monious interaction,  of  many  psychological  processes,  each  of  which 
may  be  defective  or  abnormal  in  very  varying  degree.  It  is  the 
purpose  of  this  chapter  to  describe  in  detail  these  abnormalities  of 
mind  which  go  to  the  make-up  of  amentia. 

As  to  the  nature  of  mind  itself,  there  are  two  chief  opposing  views. 
On  the  one  hand,  it  is  contended  that  mind  is  a  spiritual  something 
transcending  matter  altogether,  albeit  making  use  of  matter  (the 
central  nervous  system)  for  its  manifestations.  On  the  other  hand, 
it  is  alleged  that  mind  is  no  "  thing  "  at  all,  but  merely  a  process, 
that  it  is,  in  fact,  simply  the  sum  total  of  the  ganglionic  activity- 
of  the  brain. 

Now,  as  has  already  been  seen  in  treating  of  pathology,  all 
marked  cases  of  mental  deficiency  are  accompanied  by  imperfec- 
tions in  the  structure  of  the  cerebral  tissue.  In  some  of  the  mildest 
cases  these  changes  may  be  very  slight;  indeed,  in  such  the  im- 
perfection may  possibly  lie  more  in  an  inadequacy  of  function  than 
in  a  demonstrable  incompleteness  of  anatomical  structure.  It  is, 
however,  perfectly  justifiable  to  assume  that  in  all  cases  the  amentia 
has  a  physical  basis ;  further,  that  there  is  a  correlation  between  the 
degree  of  amentia  and  the  extent  of  material  change.  This  being 
the  case,  the  most  convenient  standpoint  from  which  to  discuss  the 
psychological  defects  of  these  persons  is  the  material  one.  What- 
ever the  relationship  between  them  may  be,  there  can  be  no  doubt 
that  particular  "  states  of  mind"  are  accompanied  by  particular 

99 


loo  Neuro-Physiology  and  Psychology- 

conditions  of  brain  activity.  At  the  same  time  it  is  not  to  be 
inferred  that  we  are  thereby  committed  to  any  view  as  to  the  nature 
of  mind  itself.  Although  the  contrary  might  be  thought,  the  im- 
perfections of  cellular  development  present  in  amentia  really  supply 
no  evidence  for  or  against  either  the  spiritualistic  or  materialistic 
doctrine  of  mind.  It  is  quite  possible  that  in  aments  there  exists 
a  normal  spiritual  mind  which  is  incapable  of  manifesting  itself 
because  of  the  faults  in  the  physical  machinery.  On  the  other 
hand,  it  is  equally  possible  that  mind  may  be  simply  the  sum  of 
various  brain  functions,  and  that  in  the  ament  mind  is  defective 
because  the  imperfection  of  anatomical  development  does  not  admit 
of  perfect  function.  But  these  are  matters  regarding  which  we 
not  only  have  no  knowledge,  but  need  here  have  no  concern. 

It  will  be  obvious  that  the  investigation  of  the  psychological 
processes  of  the  defective  mind  is  a  matter  of  very  considerable 
difficulty.  The  usual  laboratory  methods  require  not  only  co- 
operation, but  also  intelligence  on  the  part  of  the  subjects  examined, 
and  in  the  present  case  both  these  are  lacking.  It  follows  that  the 
ordinary  methods  of  the  psychological  laboratory  are  of  relatively 
little  use,  and  consequently  our  knowledge  of  the  working  of  the 
defective  mind,  even  of  the  defects  themselves,  must  be  gained  by 
observation  of  the  conduct  and  behaviour  of  these  persons  in  their 
everyday  life  and  during  the  performance  of  their  daily  occupations, 
by  conversations  conducted  so  as  to  elicit  particular  points,  and  by 
practical  tests  of  a  simple  nature.  Nevertheless,  even  by  these 
somewhat  imperfect  means  valuable  deductions  may  be  drawn, 
and  although  our  knowledge  is  still  far  from  complete,  I  think 
sufficient  information  is  available  to  permit  of  a  tolerably  accurate 
account  being  given  of  the  mental  abnormalities  of  these 
persons. 

In  giving  this  account  it  will  be  convenient  to  divide  the  subject 
into  three  chief  headings,  according  as  the  processes  relate  to 
sensation,  cerebration,  and  action.  To  a  certain  extent  such  a  division 
is  fallacious,  for  it  has  no  existence  in  Nature.  Mind  must  be  re- 
garded as  the  totality  of  nervous  activity;  it  cannot  be  divided  into 
watertight  compartments;  and  neither  sensation,  mentation,  nor 
motion  can  occur  independently  of  each  other.  Nevertheless,  the 
division  is  justifiable  for  purposes  of  description.  It  would  be 
beyond  the  scope  of  this  work  to  deal  at  any  length  with  normal 
psychological  processes ;  it  will  be  sufficient  to  give  a  brief  descrip- 


Sensation  i  o  i 

tion  of  such  facts  regarding  the  development  and  working  of  the 
normal  mind  as  are  necessary  to  an  understanding  of  the  abnor- 
malities found  in  amentia. 

SENSATION. 

The  brain  of  the  new-born  child  consists  of  a  gelatinoid  substance, 
in  which  are  embedded  myriads  of  embryonic  nerve  cells;  but 
these  cells,  or  neuroblasts,  are  so  immature  that  mind  can  hardly 
be  said  to  have  an  existence.  It  is  by  means  of  incoming  nervous 
vibrations  transmitted  through  the  peripheral  organs  and  along 
the  avenues  of  sensation  that  these  neuroblasts  derive  their  chief 
stimulus  to  growth,  and  consequently  by  which  mental  activity 
comes  into  being.  The  cerebral  cells  must,  of  course,  possess  an 
innate  capacity  to  develop;  indeed,  it  is  a  defect  of  this  capacity 
which  constitutes  the  essential  feature  of  amentia.  But  there  is 
every  reason  to  believe  that  not  only  is  this  stimulation  from  without 
vital  to  their  development,  but  that  ideation,  judgment,  reasoning, 
even  will,  are  dependent  upon  the  quantity  and  quality  of  sensa- 
tions received  from  the  outside  world.  We  may,  indeed,  say  that 
sensations  are  the  bricks  out  of  which  mind  is  built,  and  that  in 
their  absence  the  brain  cells  are  incapable  of  producing  a  single  idea. 
As  in  the  new-born  child,  sensation  may  be  present  without  reason, 
but  reason  cannot  exist  without  sensation. 

The  importance  pi  these  afferent  nerve  currents  to  mental  de- 
velopment is  shown  by  the  fact  that  where  a  peripheral  sense  organ 
is  diseased,  a  corresponding  area  of  the  brain  remains  permanently 
undeveloped;  whilst  if  communication  with  the  outside  world  is 
closed  via  several  sensory  pathways,  the  growth  of  the  brain  cells 
may  be  so  much  interfered  with  as  to  produce  a  condition  almost 
amounting  to  idiocy,  and  known  as  "  amentia  by  sense  depriva- 
tion." The  cases  of  Kaspar  Hauser,  Laura  Bridgman,  and  others, 
which  will  be  referred  to  in  a  subsequent  chapter,  are  celebrated 
instances  of  such  a  condition.  The  deprivation  of  sensory  stimuli 
may  not  only  arrest  the  growth  of  that  portion  of  the  brain  cortex 
in  which  lies  the  receiving  station,  but  may  also  lead  indirectly  to 
the  non-development  of  other  portions  which  are  functionally 
correlated.  In  short,  we  shall  not  be  wrong  in  saying  that  the 
stimulus  of  sensory  impressions  is  just  as  necessary  to  mental 
development  as  are  the  rays  of  the  sun  to  the  growth  and  matura- 
tion of  plant-life. 


102  Neuro-Physiology  and  Psychology 

There  are  three  anatomical  structures  concerned  in  sensation — 
a  peripheral  sense  organ,  a  transmitting  nerve,  and  a  central  re- 
ceiving station.  The  chief  peripheral  organs  are  those  of  eye,  ear, 
nose,  mouth,  and  skin;  but  impressions  are  also  transmitted  from 
muscles,  tendons,  joints,  and  internal  organs.  The  stations  at 
which  these  various  impressions  are  received  are  not  in  every  in- 
stance known;  but  probably  the  majority  go  to  some  portion  or 
other  of  the  brain  cortex.  It  seems  probable,  however,  that  before 
these  impulses  can  rise  into  consciousness,  they  must  be  conveyed 
by  another  relay  of  nerve  fibres  to  a  higher  centre,  possibly  situated 
in  the  prefrontal  or  parietal  regions,  so  that  the  integrity  of  this 
latter  system  is  essential  to  the  consciousness  of  these  impressions. 
In  some  cases  defects  of  sensation  are  due  to  imperfections  of  the 
lower  sensory  pathway,  and  it  is  then  usually  the  peripheral  organ 
which  is  at  fault.  In  most  cases,  however,  it  seems  likely  that  the 
defective  sensation  of  aments  is  the  result  of  the  imperfect  develop- 
ment of  the  upper  pathway — that  it  is,  in  fact,  mental  rather  than 
sensory  proper;  it  is,  nevertheless,  more  convenient  to  refer  to  aU 
anomalies  of  sensation,  however  caused,  under  the  present  heading. 

It  is  sometimes  stated  that  at  birth  the  child  can  neither  hear, 
see,  nor  feel;  but  this  is  by  no  means  the  case,  and  it  is  stated  by 
Peterson,*  as  the  result  of  a  collective  investigation  into  the  mental 
status  of  1, 060  new-born  children  in  the  lying-in  hospital  of  the 
city  of  New  York,  that  most  infants  (even  when  prematurely  bom) 
were  sensible  to  light  and  sound,  that  they  reacted  to  salt,  bitter, 
sweet,  and  sour  substances  placed  upon  the  tongue,  and  that  they 
had  cutaneous  sensibility  to  touch  and  temperature,  and  mani- 
fested signs  of  discomfort  during  the  first  day  of  life. 

We  may  now  consider  the  various  sensory  anomalies  of  aments 
in  detail. 

Taste. — The  senses  of  taste  and  smell  are  very  closely  related, 
and  are  the  first  to  make  their  appearance  in  the  normal  child.  If 
the  tongue  of  a  child  of  one  or  two  days  old  be  wetted  with  a  solu- 
tion of  sugar,  his  face  will  usually  indicate  every  appearance  of 
contentment,  and  he  will  often  make  sucking  movements.  If, 
however,  the  tongue  be  wetted  with  a  solution  of  quinine  or  of 
tartaric  acid,  he  will  usually  scream,  choke,  and  show  other  signs 
of  repulsion.  Whether  the  child  is  conscious  of  these  differences  is 
a  question  difficult  to  answer,  but  the  reaction  which  occurs  plainly 

*  F.  Peterson,  Journal  of  Nervous  and  Mental  Diseases,  February,  1912. 


Sensation 


103 


shows  that  not  only  are  the  sensory  pathways  open  to  the  receptive 
centre  in  the  brain  cortex,  but  that  a  connexion  also  exists  between 
these  centres  and  the  motor  area.  In  normal  adults  the  sense  of 
taste  differs  very  considerably.  This  is  probably  chiefly  due  to 
the  extent  to  which  it  has  been  cultivated,  and  in  professional  tea 
and  wine  tasters  it  reaches  a  very  high  degree  of  acuteness. 

In  the  milder  aments  there  is  not  usually  any  marked  impair- 
ment of  this  sense,  although  I  doubt  whether  they  have  the  delicacy 
of  taste  of  an  ordinary  person.  They  have  their  likes  and  dislikes 
with  regard  to  food,  and  they  appreciate  sweets  and  object  to  nasty 
medicines.  In  the  more  severe  grades  there  is  often  an  extreme 
defect  of  taste,  whilst  in  many  cases  there  is  marked  perversion  of 
this  sense.  Thus,  some  idiots  will  munch  sugar,  quinine,  or  even 
soap,  quite  indifferently,  and  without  the  slightest  indication  that 
they  distinguish  one  from  the  other.  Others  will  eat  and  drink 
anything  which  comes  within  their  reach,  including  wood,  leather, 
grass,  earth,  stones,  even  urine  and  faecal  matter,  or  offal  of  the 
most  putrid  description. 

It  is  stated  by  Thiemich*  that  even  as  babies  the  taste  of  im- 
beciles is  often  distinctly  defective.  One  of  the  chief  characteristics 
of  Mongolian  amentia  is  a  large  fissured  tongue,  with  hypertrophied 
papiUae,  but  this  does  not  appear  to  be  accompanied  by  any  par- 
ticular anomaly  of  taste. 

Smell. — -It  is  stated  by  Preyerf  that  the  normal  child  is  probably 
able  to  distinguish  between  the  smell  of  the  mother's  milk  and 
that  of  the  cow  as  early  as  one  day  after  birth.  It  is  quite  certain 
that  at  a  very  early  age  he  shows  a  marked  difference  of  reaction 
when  agreeable  and  disagreeable  odours  are  placed  under  his  nose, 
and  long  before  he  is  a  year  old  he  will  often  evince  a  distinct 
liking  for  particular  smells.  I  know  of  no  inquiries  which  have 
been  made  upon  the  condition  of  aments  in  early  infancy.  At  a 
later  age  those  of  mild  degree  are  able  to  perceive  most  odours, 
but  the  sense  is  usually  lacking  in  delicacy.  In  the  more  severe 
grades  there  often  seems  to  be  a  complete  absence  of  the  sense. 
Many  idiots  wiU  smell  the  most  filthy  compounds  without  the 
slightest  sign  of  repugnance,  and  some  will  sniff  strong  ammonia 
without  any  reflex  movement.  In  these  latter  a  defective  condi- 
tion of  the  olfactory  mucous  membrane  would  appear  to  be  present. 

*  Thiemich,  Deutsche  Med.  Wochenschr.,  vol.  xxvi.,  1900,  p.  34. 
t  W.  Preyer,  "  Mental  Development  in  the  Child,"  1901. 


104  Neuro-Physiology  and  Psychology 

Vision. — Sensibility  to  light  is  usually  present  in  the  normal  child 
at  birth,  as  shown  by  the  contraction  of  the  pupil  to  a  bright  light. 
Moreover,  if  a  strong  light  be  directed  on  to  the  open  eye,  there 
will  be  a  rapid  reflex  shutting  of  the  lids ;  and  if  this  does  not  occur, 
the  presence  of  some  abnormality  of  eye  or  nervous  system  is  to  be 
apprehended.  By  the  time  the  child  is  a  few  days  old  its  eyes  will 
usually  turn  to  follow  a  lighted  candle.  Some  perception  of 
objects  would  appear  to  be  developed  within  the  second  or  third 
months,  although  it  is  probably  not  until  much  later  that  any 
details  are  perceived  and  the  course  of  visual  perception  is  from 
the  gross  to  the  minute.  The  sense  of  colour  does  not  appear  until 
considerably  later,  but  some  experiments  that  I  made  upon  an 
intelligent  child  of  eighteen  months  showed  unmistakable  ability 
to  differentiate  between  red,  green,  blue,  and  yellow. 

In  the  milder  degrees  of  amentia  visual  defects  consist  chiefly  in 
an  inability  to  discriminate  between  the  slighter  differences  of  form, 
size,  or  colour.  An  octagonal  will  be  confused  with  a  hexagonal 
figure;  no  difference  will  be  noticed  between  the  size  of  a  florin 
and  half-crown;  and  although  these  patients  may  differentiate 
between  the  primary  colours,  they  are  often  unable  to  detect  differ- 
ences of  shade.  As  we  proceed  down  the  scale  of  amentia,  these 
defects  become  more  marked,  until  in  the  severe  forms  of  idiocy 
they  exist  to  a  very  pronounced  extent.  The  colour  perception 
of  the  low-grade  imbecile  and  idiot  often  seems  limited  to  the 
recognition  of  red,  and  it  is  interesting  to  note  that  this  is  the  colour 
which  is  usually  most  attractive  to,  and  first  recognized  by,  the 
normal  child.  The  appreciation  of  form  and  size  by  idiots  is  very 
imperfect,  and  although  they  will  distinguish  between  a  child  and 
a  grown-up  person,  and  between  a  man  and  a  woman,  many  of  them 
are  incapable  of  any  more  delicate  differentiation.  Voisin  states 
that  in  most  imbeciles  the  perception  of  relief  is  wanting.  The 
chief  peripheral  defects  have  already  been  described;  they  are 
strabismus,  corneal  ulcers  and  opacities,  cataract,  astigmatism, 
hypermetropia,  and,  less  frequently,  myopia.  A  few  low-grade 
?ments  are  congenitally  blind,  but  colour-blindness  does  not  appear 
to  be  commoner  than  in  normal  persons. '  These  conditions,  and, 
indeed,  all  anomalies  of  the  end  organs  of  special  sense,  are  more 
frequent  in  the  severer  grades  of  mental  deficiency. 

Hearing. — The  undeveloped  condition  of  the  auditory  t5mipanum 
and  ossicles  at  birth  preclude  the  transmission   of  sounds,   and 


Sensation  105 

consequently  the  new-born  child  is  deaf.  The  sense  of  hearing  is 
developed  very  slowly,  and  it  is  usually  not  until  the  fourth  or  fifth 
month  of  life  that  the  child  shows  indications  that  it  recognizes 
the  voices  of  its  parents. 

In  aments  developmental  anomalies  of  the  external  ear  are  very 
numerous,  but  is  very  rarely  that  such  interfere  with  hearing. 
Where  there  is  a  peripheral  cause  for  deficiency  of  this  sense,  it  is 
nearly  always  of  inflammatory  origin  and  situate  in  the  middle  ear. 
Otorrhoea  occurs  with  considerable  frequency  in  aments  of  all 
grades.  Apart  from  such  causes  complete  deafness  is  not  common 
in  the  mentally  defective.  Some  idiots  and  imbeciles  will  pay  not 
the  slightest  regard  to  questions,  to  the  sound  of  a  whistle,  or  noises 
of  many  kinds,  and  they  are  on  that  account  often  thought  to  be 
deaf.  That  this  is  due  to  want  of  interest  and  attention,  however, 
and  not  to  deafness,  is  often  shown  by  the  fact  that  they  will  at 
once  turn  upon  the  rattle  of  a  spoon  and  plate.  Itard's  wild  boy 
of  Aveyron  was  unresponsive  to  many  sounds,  and  yet  he  showed 
a  marvellous  aptitude  for  hearing  those  in  which  he  was  interested. 
In  the  feeble-minded  grade  of  amentia  there  is  not  usually  any 
marked  deficiency  of  this  sense,  although  hearing,  as  a  rule,  is 
neither  so  acute  nor  are  the  finer  differences  of  tone  so  well  detected 
as  by  the  normal  person. 

Cutaneous  Sense. — By  means  of  the  various  specialized  nerve 
corpuscles  and  end  bulbs  in  the  skin,  with  the  nerve  fibres  passing 
therefrom,  we  receive  impressions  of  touch  or  pressure,  pain  (which 
is  a  special  variety  of  touch),  and  temperature.  Peterson  is  of  the 
opinion  that  all  these  senses  exist  in  the  normal  child  from  the  first 
day  of  life,  but  my  experience  is  that  the  new-born  child  is  not 
nearly  so  responsive  to  such  stimuli  as  he  is  to  those  of  taste.  I 
have  often  failed  to  obtain  any  reaction  to  a  moderate  pin-prick  in 
different  parts  of  the  body;  the  child  may  be  pinched  without 
showing  any  movement;  and  it  is  often  some  weeks  after  birth 
before  he  evinces  disapproval  if  the  bath  is  too  hot  or  too  cold. 
From  this  early  age  cutaneous  sensibility  gradually  becomes  more 
marked,  and  by  the  time  the  child  is  a  few  months  old  it  will  show 
an  unmistakable  response  to  different  kinds  of  contact,  to  painful 
impressions,  and  to  alterations  of  temperature.  In  the  normal 
adult  the  degree  of  sensibility  to  these  stimuli  naturally  varies 
within  very  wide  limits.  There  would  also  appear  to  be  physiological 
differences  dependent  upon  sex,  as  well  as  sociological  differences, 


io6  Neuro-Physiology   and  Psychology 

probably  dependent  upon  education  and  mode  of  life.  It  is  prob- 
able that  the  same  holds  good  in  aments,  and  hence  one  can  only 
give  certain  broad  statements  of  them  as  a  whole. 

It  occasionally  happens  that  the  sense  of  touch  is  extraordinarily 
delicate,  instances  of  which  will  be  given  in  treating  of  Idiots 
Savants.  As  a  rule,  however,  although  the  milder  aments  can 
differentiate  between  substances  which  are  hard  or  soft,  rough 
or  smooth,  they  cannot  appreciate  the  finer  gradations  of  these 
qualities  so  well  as_  can  the  normal  child.  In  the  imbeciles  this 
sense  of  discrimination  is  still  less  acute,  whilst  in  the  idiots  such 
a  test  is  practically  impossible.  Alterations  of  temperature  are  cer- 
tainly appreciated  by  the  mild  aments,  although  here  also  sensibility 
would  seem  to  be  less  acute  than  in  the  normal.  In  the  lower  grades 
this  capacity  seems  to  be  wanting,  and  such  will  sit  in  front  of  the 
hottest  fire,  under  the  most  blazing  sun,  or  exposed  to  the  coldest 
wintry  blast,  without  showing  any  concern.  Pain  is  experienced  by 
feeble-minded  children;  they  will  complain  of  headache,  tooth- 
ache, or  stomach-ache;  but  here  again  it  is  exceedingly  doubtful 
whether  they  have  the  same  appreciation  as  has  the  normal  child, 
and  many  feeble-minded  persons  will  suffer  the  extraction  of  teeth 
and  other  operations  of  minor  surgery  with  relatively  little  concern . 
In  imbeciles,  and  to  a  still  greater  extent  in  idiots,  inability  to 
feel  pain  is  often  a  very  marked  characteristic.  Many  of  these 
persons  will  knock  themselves  against  floor  and  walls,  poke  their 
fingers  into  their  eyes,  pull  out  their  hair,  teeth,  or  toe-nails,  and 
injure  themselves  severely  in  many  ways,  without  showing  the 
slightest  indication  that  the  process  is  painful.  I  knew  a  boy  some 
years  ago  who  had  such  an  incurable  habit  of  sucking  his  finger 
that  the  bone  had  been  completely  denuded  of  flesh,  j^et  the 
practice  seemed  to  afford  him  extreme  pleasure  rather  than 
discomfort. 

Sensations  from  Muscles,  Tendons,  and  Joints  are  chiefly  of  use 
in  enabling  us  to  appreciate  the  weight,  size,  and  position  of  objects. 
Such  impressions  also  play  a  very  important  part  in  deteraiining 
the  quantity  and  quality  of  muscular  contractions,  and  are  there- 
fore essential  to  the  maintenance  of  the  equilibrium  of  the  body, 
to  walking,  running,  jumping,  and,  indeed,  to  any  action  requiring 
muscular  co-ordination.  It  seems  likely  that  in  the  normal  infant 
sensations  of  this  order  are  very  poorly  developed  at  birth,  and  that 
they  owe  most  of  their  development  to  practice;  certainly,  as  a 


Sensation  107 

result  of  this,  co-ordination  may  reach  a  very  high  degree  of  per- 
fection, as  is  well  seen  in  the  performance  of  such  delicate  manipu- 
lations as  violin  and  piano  playing,  and  the  like. 

It  occasionally  happens  that  the  feeble-minded  evince  a  very 
high  degree  of  manipulative  skill  in  certain  directions,  and  in  such 
cases  it  is  clear  that  impressions  of  the  kind  we  are  now  considering 
must  be  quite  equal,  if  not  superior,  to  those  in  ordinary  persons. 
This,  however,  is  exceptional,  and  if  the  mentally  defective  child 
be  asked  to  compare  the  weights  of  small  pill-boxes  filled  with  a 
varying  number  of  coins  or  shot,  by  placing  them  on  the  palm  of 
his  hand,  he  will  usually  be  found  distinctly  inferior  to  the  normal. 
In  the  lower  grades  of  defects  such  a  test  is  impossible,  but,  judging 
from  their  general  clumsiness  of  manipulation,  body  balance,  and 
movement,  it  would  appear  that  such  impressions  cannot  be  of  a 
very  high  order. 

Under  the  term  Organic  Sensations  we  may  include  not  only 
afferent  impressions  from  the  internal  organs,  but  also  such  sensa- 
tions as  those  of  thirst,  hunger,  and  the  sexual  instincts.  In  the 
mildest  cases  of  amentia  there  would  not  appear  to  be  any  marked 
abnormality  in  these  respects.  Feeble-minded  persons  feel  the 
pangs  of  hunger  and  thirst,  are  conscious  of  bodily  aches  and  pains 
and  general  discomfort,  and  have  sexual  desires;  sometimes,  indeed, 
these  latter  are  inordinately  developed.  Nevertheless,  on  the  whole, 
I  am  disposed  to  think  that  their  feelings  in  these  respects  as  a  rule 
are  not  so  keen  as-  in  the  non-defective  individual.  In  the  more 
severe  grades  of  amentia  defects  of  organic  sensation  become  more 
pronounced.  The  painful  sensations  which  accompany  disease  are 
•often  not  appreciated,  and  these  persons  will  be  acutely  ill  with 
alveolar  abscess,  pneumonia,  gangrene  of  the  lung,  or  tuberculosis, 
without  making  any  complaint.  In  the  profound  idiots  such 
primitive  organic  sensations  as  those  of  hunger  and  thirst  are 
wanting,  and  such  persons  would  die  of  starvation  if  not  fed.  It 
often  happens  that  these  cases  show  an  absence  of  the  instinct 
of  sucking  from  birth.  On  the  other  hand,  many  of  the  less  pro- 
nounced idiots  are  extraordinarily  gluttonous,  and  will  voraciously 
devour  almost  anything  coming  within  their  reach. 


io8  Neuro-Physiology  and  Psychology 

CEREBEATION. 

All  impressions  reaching  the  brain  by  the  various  sensory  path- 
ways we  have  just  described  tend  to  be  converted  into  action,  and 
in  some  instances  action  takes  place  as  an  immediate  response 
without  any  consciousness  of  the  incoming  sensation.  Usually, 
however,  the  transference  is  not  thus  simple.  Between  the  sensation 
and  the  motor  response  there  are  interposed  a  variety  of  processes 
of  the  utmost  complexity,  the  nature  and  jnodtts  operandi  of  which 
are  far  from  being  understood.  Probably  many  reflex  movements 
are  even  accompanied  by  complex  processes  of  this  kind,  which  ^ 
although  subconscious  at  the  time,  may  subsequently  rise  into- 
consciousness.  These  internal  processes  are  commonly  termed 
"  psychological  "  as  opposed  to  "  physiological  ";  but  there  can  be 
no  doubt  that  they  have  as  their  concomitants  definite  physiological 
states  of  the  brain;  that  they  are,  moreover,  dependent  upon 
anatomical  peculiarities  of  brain  structure,  so  that  the  differentia- 
tion is  probably  only  a  verbal  one.  It  is  these  internal  processes, 
which  comprise  what  may  be  termed  the  "  cerebration  "  of  the 
individual,  that  we  have  now  to  consider. 

Perception. — It  is  probable  that  the  first  of  these  processes  to- 
come  into  being  in  the  child  is  that  of  perception.  The  various 
sensory  receptive  stations  are  connected  by  relays  of  nerve  fibres 
with  a  higher  level  station,  and  into  this  the  afferent  vibrations  pass 
to  be  combined  and  to  rise  into  consciousness  as  a  perception.  It 
seems  doubtful  whether  we  can  ever  be  conscious  of  a  simple  sensa- 
tion as  such:  the  blueness  of  the  sea  or  sky  is  always  associated 
with  other  attributes,  smells  invariably  give  rise  to  compound 
images,  and  the  consciousness  of  an  impression  from  the  skin  is 
made  up  of  other  sensations  than  those  of  mere  touch.  The  presence 
of  an  intricate  system  of  association  fibres  causes  all  sensations 
simultaneously  experienced  to  "  cling  together,"  and  hence  the 
consciousness  of  an  object  is  always  a  compound  mental  picture; 
these  associates  being  recalled  upon  the  presentment  of  any  of  the 
elementary  vibrations  which  go  to  the  make-up  of  the  composite 
whole.  Amongst  the  most  important  of  these  afferent  vibrations 
are  those  which  serve  to  relate  the  object  in  time  and  space,  and  a 
perception  may  be  said  to  be  a  cognition  of  various  associated 
sensations  thus  related  aroused  b}^  stimulation  from  the  actual 
object   without.     Sensations   become   conscious   perceptions   as   a 


Cerebration  ]  09 

necessary  result  of  the  development  of  certain  brain  pathways, 
and  every  normal  brain  is  endowed  with  the  faculty  of  thus  form- 
ing perceptions.  It  seems  probable,  indeed,  that  some  form  of 
conscious  perception  is  present  in  all  life  forms,  even  in  the  protista, 
although  the  quality  and  quantity  of  perception  will  necessarily 
vary  with  the  complexity  of  cerebral  development.  It  will  be 
obvious,  therefore,  that  the  nature  of  a  person's  perceptions  must 
be  primarily  dependent  upon  the  integrity  of  his  sensory  apparatus, 
and  where  this  latter  is  faulty,  consciousness  must  be  similarly  in- 
complete. But  this  is  not  all.  Everyone  is  familiar  with  the  im- 
perfect, misty  consciousness  of  passing  objects  which  occurs  when 
the  thoughts  are  otherwise  occupied.  For  instance,  during  the 
reading  of  an  interesting  book,  extraneous  objects  may  be  pre- 
sented to  our  senses,  a  bell  may  ring,  or  a  person  come  into  the 
room  and  go  away  again  without  our  "  taking  in  "  who  it  is.  And 
yet  there  is  no  defect  of  sensation;  impressions  of  sight  and  sound 
have  travelled  to  the  brain,  and  may  subsequently  flash  into  con- 
sciousness to  form  a  vivid  mental  picture  of  what  has  happened, 
but  for  the  time  being  they  are  unnoticed,  for  the  reason  that  our 
attention  is  focussed  elsewhere.  This  subject  of  attention  will  be 
considered  immediately,  but  it  is  clear  that  other  processes  than 
those  concerned  in  mere  sensation  are  necessar}^  for  accurate  per- 
ception, and  I  am  inclined  to  think  that  the  imperfect  perceptions 
of  aments,  their  lack  of  acuteness  and  feeble  intensity,  are  in  most 
cases  due  more  to  imperfect  attention  or  other  defect  of  cerebra- 
tion than  to  imperfection  of  sensation  proper.  It  is  to  such  defects 
of  perception  that  their  inability  to  discriminate  the  finer  qualities 
of  objects  is  due. 

Attention. — The  act  of  attention  consists  in  the  focussing  of  con- 
sciousness upon  a  perception  or  idea,  to  the  exclusion  of  other 
ideas.  It  may  be  spontaneous  and  involuntary  or  active  and  volun- 
tary, and  it  is  necessary  to  consider  these  separately. 

Spontaneous  attention  occurs  when  a  perception  or  idea  is  so 
sudden,  so  intense,  or  so  unusual,  that  it  holds  consciousness  auto- 
matically and  without  any  mental  effort.  Of  this  nature  is  the 
flash  of  lightning,  the  peal  of  thunder,  or  any  sight  or  other  sensa- 
tion to  which  the  beholder  is  utterly  unaccustomed.  This  form  of 
attention  is  characteristic  of  children  and  the  lower  animals,  and 
although,  of  course,  dependent  upon  the  nature  of  the  stimulus, 
variations  in  it  are  more  influenced  by  the  condition  of  the  cerebral 


iio  Neuro-Physiology  and  Psychology 

cells  with  regard  to  their  inherent  excitability.  It  may  be  com- 
pared to  the  violent  shock  inflicted  upon  the  cerebral  mass  of  the 
child  of  a  few  weeks  old  by  any  sudden  noise,  and  which  results 
in  a  general  start  of  the  whole  body ;  with  the  development  of  con- 
sciousness this  general  bodily  change  is  often  still  seen  when  atten- 
tion is  involuntarily  aroused. 

In  the  lowest  types  of  idiocy  feeling  is  very  rudimentary,  and 
hence  even  this  spontaneous  form  of  attention  is  defective.  But 
even  where  perception  is  present  the  cerebral  excitability  may  be 
so  diminished  as  to  bring  about  a  considerable  deficiency  of  spon- 
taneous attention,  and  this  is  the  case  with  many  idiots  and  im- 
beciles as  well  as  with  a  few  feeble-minded.  Such  persons  are  dull 
and  lethargic ;  they  seem  to  be  utterly  unconcerned  by  anything 
happening  around  them,  and  they  have  no  curiosity  or  initiative. 
If  in  school,  they  sit  at  their  desks  gazing  vacantly  in  front  of  them ; 
if  in  the  playrgound,  they  stand  aloof  in  a  corner,  without  the 
slightest  desire  to  take  part  in  the  games  of  their  companions. 
They  respond  tardily,  or  not  at  all,  when  addressed,  are  stolidly 
indifferent  when  interfered  with,  and  are,  in  fact,  so  generally  inert 
as  to  give  rise  to  the  impression  that  they  are  deaf.  But  there  is 
no  real  sensory  defect,  and  the  condition  is  simply  one  of  general 
brain  inertia.  By  appropriate  methods  of  training,  the  excitability 
of  the  brain  cells  may  often  be  increased  and  the  child  aroused 
out  of  his  lethargy. 

Active  or  voluntary  attention  takes  place  when  the  idea  or  sensa- 
tion attended  to  has  no  compelling  power  of  its  own.  Attention  to 
it  may,  indeed,  be  distasteful,  and  the  focussing  of  consciousness 
upon  it,  so  that  other  ideas  and  impressions  are  for  the  time  being 
shut  out,  demands  a  very  considerable  effort  of  volition.  It  is 
plain  that  attention  of  this  kind  is  indispensable  to  the  acquirement 
of  knowledge  and  the  conduct  of  human  affairs,  and  the  person  in 
whom  it  is  greatly  lacking  will  cut  but  a  sorry  figure  in  life.  Its 
defect  is  called  "  aprosexia." 

Defect  of  voluntary  attention  is  present  in  a  large  number  of 
aments.  They  are  quite  incapable  of  concentrating  their  thoughts 
upon  a  particular  subject,  and  they  consequently  have  no  power  for 
sustained  work.  It  follows  that  their  education  and  training  is 
exceedingly  difficult.  Persons  of  this  type  differ  from  those  lack- 
ing in  spontaneous  attention  in  several  noteworthy  points.  Instead 
of  being  heavy  and  lethargic,  they  are  often  active  and  restless,  and 


Cerebration  i  1 1 

attracted,  but  distracted,  by  every  sight  and  sound  around  them. 
The  clinical  signs  are  thus  the  exact  opposite  of  the  former  type, 
and  at  first  sight  would  appear  to  result  from  an  excessive,  instead 
of  diminished,  nervous  excitability.  This,  however,  is  by  no  means 
necessarily  the  case,  and  very  often  the  fault  seems  to  lie  rather 
in  a  defective  power  of  co-ordination  and  control.  It  is  often 
associated  with  the  presence  of  tricks  and  habits.  As  Maudsley 
says,  "  The  person  who  is  unable  to  control  his  own  muscles  is 
incapable  of  attention." 

This  condition  of  imperfect  muscular  control  and  defective  atten- 
tion is,  of  course,  characteristic  of  normal  infancy ;  but  whereas  it  is 
but  a  phase  in  the  development  of  the  healthy  child,  it  is  a  much 
more  persistent,  and  often  permanent,  condition  in  the  mentally 
defective.  It  is  undoubtedly  responsible  for  much  of  the  faulty 
perception  and  discrimination  of  these  persons,  and  since  our  stock 
of  ideas  is  dependent  upon  the  multiplicity  and  accuracy  of  sensa- 
tions from  the  outer  world,  some  would  see  in  this  defective  power 
of  attention  the  psychological  fons  et  origo  of  mental  deficiency. 
But  whilst  admitting  to  this  faculty  a  most  important  share  in  the 
quantity  and  quality  of  the  intellectual  processes,  its  lack  in  these 
persons  is  not  sufficient  to  account  for  their  imperfect  reason  and 
want  of  common  sense.  Moreover,  there  are  many  aments  in 
whom  attention  is  not  lacking.  We  must  therefore  consider  the 
defective  attention  of  aments,  not  as  the  prime  cause,  but  as  only 
one  factor  of  that  general  imperfection  of  mental  faculty  which 
constitutes  amentia. 

Association. — I  have  already  alluded  to  the  process  of  associa- 
tion in  speaking  of  perception.  Its  physical  basis  probably  lies  in 
the  systems  of  horizontally  crossing  fibres  which  will  be  seen  figured 
in  Plate  I.,  and  which  serve  to  connect  together  the  various  cell 
layers  of  the  cerebral  cortex.  It  has  already  been  remarked  that 
there  is  a  numerical  deficiency  of  these  fibres  in  cases  of  amentia 
and  dementia.  Whether  in  aments  such  paucity  is  a  primary 
deficiency,  or  whether  it  is  a  secondary  result  of  other  causes — such , 
for  instance,  as  a  defective  attention  leading  to  imperfect  percep- 
tion and  consequently  under-development  of  the  association  path- 
ways— must  be  a  moot  point ;  but  there  can  be  little  doubt  that  the 
degree  of  development  of  these  fibres  bears  a  direct  relation  to  the 
mental  capacity  of  the  individual,  and  that  the  wealth  of  associa- 
tions present  in  any  person  is  a  factor  of  the  utmost  importance  in 


112  Neuro-Physiology  and  Psychology 

determining  his  intellectual  status.  This  will  be  seen  more  clearly 
when  we  come  to  consider  the  acts  of  ideation  and  reasoning.  If 
a  healthy,  intelligent  child  of  between  three  and  four  years  be  asked 
to  describe,  from  memory,  some  common  object — such,  for  in- 
stance, as  a  cat,  a  chair,  or  table — and  if  a  little  direction  be  given 
to  his  thoughts  by  not  too  leading  questions,  a  very  good  estimate 
will  be  formed  as  to  his  capacity  of  memory  and  association.  To 
those  unacquainted  with  the  mind  of  an  intelligent  child  of  this 
age  the  result  is  often  surprising,  and  contrasts  in  an  extremely 
marked  manner  with  a  similar  examination  of  the  mentally  defec- 
tive child  of  much  greater  age.  I  have  often  found  the  mental 
images  in  a  defective  child  of  twelve  or  even  fourteen  years  to  be 
far  simpler,  and  to  have  only  a  fraction  of  the  associations  which 
are  present  in  the  former  case.  In  the  lower  aments  the  deficiency 
is  still  more  marked,  although  such  an  examination  in  their  case 
is  extremely  difficult.  Other  methods  by  which  the  extent  of 
association  in  mild  aments  may  be  tested  are  those  known  as  the 
"  part -wholes,"  "  genus-species,"  and  "  opposites  "  tests,  which 
together  with  other  mental  tests  will  be  described  in  Chapter  XVII. 
By  all  of  these  it  may  be  shown  that  the  mentally  defective  are 
distinctly  inferior  to  the  non-defective  class.  Miss  Norsworthy,* 
who  has  conducted  a  large  number  of  observations  upon  mentally 
deficient  children  in  America,  finds  that  in  the  first  two  of  these 
tests  only  g  per  cent,  of  feeble-minded  children  reached  that  degree 
of  efficiency  which  was  attained  by  one-half  of  the  normal  children, 
and  in  the  third  test  none  of  them  reached  this  standard. 

Memory  is  a  process  which  is  similarly  indispensable  to  ideation 
and  reasoning.  It  is  obviously  also  essential  in  the  practical  per- 
formance of  even  the  simple  affairs  of  everyday  life.  The  process 
of  memory  consists  of  two  factors — namely,  retention  and  recall. 
Recall  is  dependent  upon  association,  since  the  larger  the  number 
of  links  possessed  by  the  particular  fact  experienced,  the  greater  will 
be  the  ease  with  which  it  can  be  drawn  up  to  the  surface  of  con- 
sciousness when  it  is  again  required.  It  follows  that  a  good  general 
memory  and  wealth  of  association  go  hand  in  hand.  Ease  of  recall 
is  also  dependent  upon  the  degree  of  retentiveness  or  "  persevera- 
tion." The  conditions  which  cause  an  impression  to  be  "  retained  " 
are  not  fully  understood,  but  they  are  probably  partly  the  physio- 

*  N.  Norsworthy,  "  The  Psychology  of  Mentally  Deficient  Children,"  New 
York,  1906. 


Cerebration  113 

logical  constitution  of  the  brain  cells,  partly  the  intensity  of  the 
sensation  experienced,  and  partly  the  degree  of  attention  exerted. 
Thus,  as  is  well  known,  occurrences  which  are  unusual,  particularly 
striking,  or  upon  which  the  attention  has  been  strongly  concen- 
trated, tend  to  be  more  easily  and  longer  retained  (or,  in  other 
words,  more  readily  recalled)  than  those  of  everyday  occurrence, 
or  to  which  no  particular  thought  has  been  given.  It  is  as  if,  under 
such  conditions,  a  deeper  channel  had  been  worn,  which  more 
readily  permits  of  the  return  flow  which  takes  place  in  the  act  of 
recollecting.  From  this  it  follows  that  association  and  attention 
are  the  chief  factors  involved  in  memory. 

It  is  in  agreement  with  their  defective  association  that  we  find 
the  general  power  of  memory  of  aments  to  be  decidedly  below  the 
noraial.  If  an  ament  and  a  normal  child  be  each  given  a  number 
of  tasks  to  perform  of  a  quite  simple  nature,  the  failing  of  the  former 
will  usually  be  very  apparent,  in  that  he  will  almost  certainly  forget 
a  quarter  or  half  of  them.  Over  and  over  again  parents  will  say 
that  if  their  feeble-minded  child  be  sent  on  three  errands,  he  will 
forget  one  or  two  of  them,  and  I  have  tested  this  myself  on  many 
occasions.  Galton,  testing  the  memory  of  imbeciles  by  means  of 
a  series  of  haphazard  numerals,  found  that  few  of  them  could 
repeat  more  than  four,  a  number  greatly  inferior  to  those  of  which 
a  normal  child  is  capable.  Miss  Norsworthy,  using  the  tests  of 
related  and  unrelated  words,  found  that  only  5  per  cent,  of  feeble- 
minded children  came  up  to  the  average  of  the  normal;  and 
F.  Smedley  found  that  the  incorrigible,  defective,  and  truant  boys 
of  the  John  Worthy  School  (U.S.A.)  were  decidedly  lower  in 
memory  power  than  the  pupils  of  normal  schools,  and  that  the 
disparity  was  increasingly  marked  at  the  higher  ages.  As  will  be 
described  in  a  subsequent  chapter,  some  aments  are  characterized 
by  a  really  remarkable  power  of  repeating  poetry,  remembering 
names  and  dates,  and  other  similar  feats  of  memory,  and  in  not  a 
few  aments  the  tenacity  of  memory  for  striking  events  and  certain 
isolated  occurrences  which  have  appealed  to  them  does  not  seem  to  be 
markedly  inferior  to  that  of  the  normal  person.  But  such  memory  is 
particular  rather  than  general;  it  seems  to  be  due  to  the  fact  that 
spontaneous  or  active  attention  have  resulted  in  the  fomiation  of 
such  a  facile  nervous  pathway  that  recall  is  easy,  and  in  the  majority 
of  those  cases  which  even  evince  phenomenal  memory  in  certain 
directions  their  general  power  of  recall  is  decidedly  poor.     I  know 


114  Neuro-Physiology  and  Psychology 

a  man  of  this  kind  who  will  reel  off  facts  of  ancient  history  literally 
by  the  yard,  but  he  finds  considerable  difficulty  in  saying  what  he 
had  for  breakfast,  or  what  were  the  happenings  of  yesterday. 

Ideation,  Imagination,  Thought. — An  idea  may  be  said  to  be  a 
mental  image  of  a  thing  not  actually  present  to  the  senses.  It  is, 
in  fact,  a  picture  brought  into  consciousness,  not  by  a  direct  sensory 
stimulus  from  without,  but  by  stimulation  from  within.  Ideas 
differ  from  perceptions,  therefore,  merely  in  the  physiological 
manner  of  their  production. 

If  ideas  follow  one  another  simply  as  a  result  of  associative 
recall — that  is,  if  each  succeeding  picture  arises  into  consciousness 
merely  in  consequence  of  the  haphazard  stimulation  by  elements  of 
the  one  which  has  preceded  it — we  have  that  condition  of  fantasy, 
reverie,  or  day-dreaming,  which  is  so  familiar.  If,  by  an  effort  of 
attention,  the  stream  of  ideas  is  kept  within  a  particular  channel, 
so  that  the  series  has  a  willed  relationship,  we  may  describe  it  as 
thought.  It  follows,  therefore,  that  all  the  processes  we  have 
hitherto  considered — namely,  sensation,  perception,  association, 
attention,  and  memory — are  necessary  for  the  formation  of  ideas; 
and,  generally  speaking,  that  form  of  ideation  known  as  "  reverie  " 
or  "  imagination  "  is  dependent  upon  a  complexity  plus  a  nimbleness 
or  facility  of  association ;  whilst  that  of  thought  requires  that  good 
association  shall  be  accompanied  by  a  considerable  power  of 
attention. 

This  being  the  case,  in  view  of  the  defects  of  these  processes 
which  have  been  described  as  present  in  aments,  it  is  not  surprising 
to  find  that  ideation  is  of  a  very  imperfect  character.  Fantasy, 
reverie,  and  day-dreaming  occur  in  some  of  the  milder  aments, 
although  in  a  much  simpler  form  than  in  the  normal  person.  More- 
over, many  of  those  of  unstable  type  have  delusions  without  either 
mental  exaltation  or  depression.  A  few  are  even  capable  of  a 
certain  amount  of  constructive  imagination,  as  is  shown  by  their 
skill  in  drawing  and  mechanical  invention,  as  well  as  by  the  cunning 
with  which  they  commit  thefts  and  the  ingenuity  with  which  they 
invent  plausible  lies  to  screen  themselves  and  incriminate  their 
companions.  On  the  whole,  however,  there  seems  to  be  a  decided 
defect  in  the  faculty  of  imagination  in  aments.  The  higher  types 
may  copy  a  drawing  or  design ;  they  may  produce  faithful  models  of 
flowers  or  fruit;  they  may,  indeed,  have  a  very  high  degree  of 
manipulative  skill ;  but  their  work  is  generally  a  slavish  imitation,. 


Cerebration  1 1  5 

and  they  hardly  ever  originate.  And  when  they  do,  the  result  is 
not  usually  creditable  to  their  imagination.  If  mentally  defective 
school-children  be  watched  drawing,  brick-building,  or  pattern- 
making,  it  will  generally  be  found  that  they  follow  the  same  stereo- 
typed plan,  and  that  they  do  not  evince  a  fraction  of  the  originality 
shown  by  the  normal  child.  In  the  imbeciles  and  idiots  the  de- 
ficiency is  much  more  pronounced. 

It  necessarily  follows  also  that  the  capacity  of  aments  for  con 
secutive  thought  is  extremely  limited,  whilst  conversation  readily 
reveals  the  general  crudity  and  childishness  of  their  ideas.  One  may 
indeed  say  that  the  intellectual  life  of  these  persons  consists  almost 
entirely  of  perceptions,  and  not  conceptions — that  is,  of  simple 
ideas  relating  to  objects  which  are  immediately  present  to  their 
senses.  I  cannot  agree,  however,  with  the  statement  so  often  made, 
that  the  ament  is  utterly  wanting  in  the  capacity  for  forming 
abstract  ideas.  It  is  true  that  the  concrete  is  much  more  readily 
grasped  than  the  abstract,  and  it  is  interesting  to  note  that  many 
feeble-minded  school-children  .find  it  much  easier  to  express  their 
ideas  by  means  of  a  drawing  than  by  a  word ;  but  there  is  no  doubt 
that  many  of  the  milder  grade  are  quite  capable  of  conceiving  such 
universals  as  mankind  and  womankind,  goodness  and  badness,  and 
the  like.  Of  abstracting  in  the  logical  sense,  however,  most  of  them 
are  probably  quite  incapable. 

Judgment  and  Reasoning.— To  reason  is  to  think,  but  thinking 
is  not  reasoning.  Most  of  our  thinking  consists  simply  of  a  review 
of  mental  images,  which  successively  rise  into  consciousness  in 
accordance  with  the  laws  governing  association.  The  thought  which 
is  past  has  suggested  that  now  present,  and  this  in  its  turn  suggests 
that  to  come,  the  series  depending  upon  previous  experience  (per- 
ceptions) and  the  type  of  our  mental  constitution.  Thinking  is 
thus  to  a  great  extent  a  form  of  reverie,  although  thoughts 
may  be  directed  and  confined  to  a  certain  channel  by  an  effort 
of  will. 

Reasoning,  on  the  other  hand,  necessitates  not  only  a  definite 
and  deliberate  effort  of  mind,  but  it  also  involves  other  processes 
which  are  not  concerned  in  mere  thinking.  Without  attempting 
to  discuss  wh9.t  these  are,  or  the  manner  of  their  working,  it  may 
briefly  be  said  that  reasoning  consists  in,  firstly,  the  deliberate 
contemplation  of  certain  ideas;  the  abstraction  from  these  of  their 
essential  attributes;  the  comparison  of  these  abstractions;  and, 


1 1 6  Neuro-Physiology  and  Psychology 

finally,  the  construction  of  an  idea  or  judgment  which  is  new  to 
our  mental  experience. 

It  is  commonly  stated  that  language  is  necessary  for  reasoning, 
but  this  depends  upon  the  precise  meaning  we  attach  to  the  term 
"  reasoning."  For  the  higher  forms  of  abstract  reasoning  a  docket- 
ing process  by  means  of  words  is  clearly  essential,  but  there  is  not 
the  slightest  doubt  that  reasoning  in  a  real  sense  may  take  place 
without  this.  There  are  many  persons  gifted  with  an  extraordinary 
flow  of  language  who  yet  possess  little  reason;  on  the  other  hand, 
it  is  quite  clear  that  both  the  word-deaf  and  the  child  who  has  not 
yet  acquired  the  faculty  of  speech  are  capable  of  this  power.  The 
presence  of  reasoning  may  be  seen  in  a  hundred  ways  in  the  normal 
child  from  the  sixth  month  of  life,  and,  as  has  been  well  pointed  out 
by  Preyer,  it  undergoes  a  great  development  through  the  influence 
of  play.  By  means  of  this  the  normal  child  is  led  to  make  mental 
comparisons,  to  draw  deductions  from  those  comparisons,  and  hence 
to  evolve  thoughts  entirely  new  to  his  previous  experience.  There 
can  be  no  doubt  that  sensation,  perception,  discrimination,  atten- 
tion, and  reason,  are  largely  developed  by  a  child's  spontaneous 
play.  The  child  of  a  few  months  will  at  first  get  very  angry  be- 
cause it  cannot  succeed  in  putting  a  big  toy  through  a  hole  which 
is  much  too  small  for  it,  but  long  before  it  has  learned  to  speak  it 
has  developed  the  sense  to  see  the  impossibility  of  the  attempt. 
During  its  first  year  of  life  an  intelligent  child  who  wishes  to  climb 
into  a  chair  which  is  too  high  will  accomplish  its  purpose  by 
scrambling  up  from  a  footstool,  which  it  has  placed  in  position  from 
another  part  of  the  room.  But  the  mentally  defective  child  of 
much  greater  age  cannot  do  this,  for  such  reasoning  involves  mental 
activities  of  a  higher  order  than  he  possesses. 

I  regard  the  chief  characteristic  of  amentia  as  a  defect  of  this 
capacity.  This  defect  reaches  its  maximum  in  the  most  pronounced 
degree  of  amentia,  and  in  the  majority  of  idiots  the  ability  to  reason 
is  completely  absent.  The  absolute  idiots  would  even  die  of 
starvation  in  the  midst  of  food,  if  they  were  not  fed.  The  imbeciles 
possess  some  capacity  for  reasoning,  although  of  a  very  simple 
order;  whilst  in  the  feeble-minded  grade  the  defect  is  still  less 
evident.  A  feeble-minded  child  who  is  ignorant  of  mone^^  values, 
if  offered  the  choice  of  a  shilling  or  half-crown,  may  choose  the 
latter  "  because  it  is  bigger."  Some  defect,  however,  is  present  in 
every  grade  of  amentia;  and  if  I  were  compelled  to  specify  which 


Cerebration  117 

particular  mental  abnormality  was  chiefly  responsible  for  the 
maladjustment  of  their  conduct,  I  should  certainly  say  it  was  the 
one  we  are  now  considering. 

I  sent  a  feeble-minded  and  an  imbecile  youth  respectively  to 
fetch  an  article  out  of  a  room,  the  door  of  which  had  been  locked 
and  the  key  hung  up  in  a  conspicuous  place  above  the  handle. 
The  feeble-minded  one  went  to  the  door,  tried  the  handle,  found  it 
locked,  seemed  nonplussed  for  a  moment,  then  saw  and  took  down 
the  key,  opened  the  door,  and  performed  his  task.  The  imbecile 
tried  the  door,  gazed  vacantly  at  the  key,  turned  roimd,  and  said, 
"  Locked."  Upon  being  asked  where  the  key  was,  he  pointed,  and 
said,  "  There,"  but  when  again  told  what  to  fetch  he  made  no  effort 
to  use  the  key.  Upon  my  placing  the  key  in  the  lock,  he  turned  it, 
opened  the  door,  and  got  the  desired  article.  A  somewhat  similar 
test  was  tried  between  two  other  children.  It  was  a  pouring  wet 
day,  and  I  placed  an  umbrella  near  the  door,  and  told  them  to  fetch 
a  certain  flower  out  of  the  garden.  The  feeble-minded  child  opened 
the  door,  saw  the  rain  coming  down  in  torrents,  and,  after  a  pause, 
picked  up  and  opened  the  umbrella.  The  imbecile  would  have 
got  wet  through  had  he  not  been  called  back,  but,  when  given  the 
umbrella,  had  enough  sense  to  open  it  before  going  out. 

But  although  there  are  many  mild  defectives  capable  of  such 
simple  reasoning  as  these  feeble-minded  children,  and  many  who 
can  not  only  work  well,  but  can  actually  earn  a  living  wage,  that 
wage  is  never  equal  to  what  could  be  earned  by  a  normal  person  of 
similar  age.  I  know  many  feeble-minded  adults  who  are  regularly 
employed.  They  are  careful,  industrious,  and  thoroughly  trust- 
worthy, but  the  work  they  are  capable  of  and  the  money  they  can 
earn  is  only  equivalent  to  that  of  a  boy  or  girl  of  school  age,  and 
this  for  the  reason  that  they  have  not  sufficient  intelligence  to 
cope  with  any  situation  needing  judgment,  or  do  any  work  which 
is  not  of  a  strictly  routine  character.  Moreover,  the}^  find  it  im- 
possible to  lay  out  the  money  they  earn  so  as  to  provide  themselves 
with  the  necessities  of  life,  and  in  the  absence  of  some  supervision 
and  kindly  control  they  would  rapidly  come  to  hopeless  want. 

Volition. — The  psychological  state  which  we  term  "will," 
"  determination,"  or  "  purpose,"  is  easier  of  appreciation  than  of 
description,  and  it  is  plain  that  it  plays  a  very  important  part  in 
the  regulation  of  conduct.  Will,  indeed,  is  inseparable  from  action, 
and  in  order  to  understand  its  nature  it  is  necessary  to  allude  to 


ii8  Neuro-Physiology  and  Psychology 

the  chief  forms  of  movement.  As  will  be  more  fully  shown  presently, 
the  earliest  movements  of  the  new-born  child  are  of  three  kinds — 
namely,  instinctive,  reflex,  and  spontaneous.  With  the  develop- 
ment of  consciousness,  however,  the  child  acquires  the  power  of 
forming  mental  images,  and  when  this  image  is  of  a  movement,  it  is 
spoken  of  as  a  motor  idea.  Every  voluntary  act  must  be  preceded 
by  a  motor  idea  of  the  act  to  be  performed.  The  first  willed  move- 
ments are  usually  noticed  in  a  healthy  child  during  the  third  month. 
At  this  age  it  will  smack  its  lips  and  suck  its  tongue  at  the  sight  of 
the  breast  or  bottle ;  it  will  smile  at  relatives  whom  it  knows,  but 
not  at  strangers ;  and  it  will  turn  its  head  to  follow  the  movements 
of  a  person  about  the  room.  These  actions  are  neither  instinctive 
nor  reflex,  but  are  plainly  the  result  of  intention  and  will,  and  they 
are  each  preceded  by  a  mental  image  of  the  movement  which  the 
child  desires  to  make.  With  the  establishment  of  such  motor 
ideas  manifestations  of  will  become  increasingly  frequent,  and  I 
have  seen  a  child  of  eight  and  a  half  months,  whilst  being  given 
water  with  a  spoon  from  a  glass,  seize  the  glass  in  his  hands,  carry 
it  to  his  mouth,  and  drink  with  great  delight.  By  the  twelfth 
month  it  is  obvious  that  the  intelligent  child  has  very  definite 
ideas  as  to  what  it  wants  to  do,  and  a  few  months  later,  when  he  is 
beginning  to  toddle  and  has  command  of  a  few  words,  he  is  capable 
of  an  amount  of  will  power  in  his  endeavours  to  put  his  motor  ideas 
into  execution  which  may  tax  the  energy  of  his  nurse  in  no  incon- 
siderable degree. 

We  see,  therefore,  that  the  act  of  willing  is  dependent  upon  the 
presence  of  a  motor  idea  of  some  particular  action ;  consequently  the 
faculty  for  ideation  is  a  pre-requisite  to  will.  But  before  such  idea 
can  become  translated  into  action,  it  must  attain  a  certain  domin- 
ance, and  we  may  regard  what  is  usually  spoken  of  as  "  strong 
will  "  as  neither  more  nor  less  than  the  fixity  with  which  an  idea 
can  be  kept  before  consciousness  to  the  exclusion  of  other  ideas 
of  a  possibly  neutralizing  tendency.  Differences  in  this  respect 
may  be  due  to  the  physiological  constitution  of  the  brain.  But  it 
may  happen,  and  often  does,  that  the  idea  would  tend  to  action 
which  is  painful,  distasteful,  and  disadvantageous  to  the  individual. 
Its  dominance  and  consequent  effectiveness  can  then  only  be 
secured  when  it  is  reinforced  by  other  ideas,  such,  for  instance,  as 
those  of  duty,  honour,  or  future  (as  opposed  to  present)  advantage. 
Such    reinforcement    necessitates    the    effort    of    attention,     and 


Cerebration  119 

hence  attention  plays  an  important  part  in  the  process  of 
volition. 

It  is  often  assumed  that  intensity  or  violence  of  action  is  synony- 
mous with  strength  of  will,  but  this  is  by  no  means  the  case.  Such 
action,  it  is  true,  often  results  from  the  presence  of  a  very  vivid 
motor  idea,  but  the  response  is  so  immediate  as  to  be  more  in  the 
nature  of  an  uncontrolled  reflex  than  a  real  volitional  movement, 
and  strength  of  will  is  much  more  evidenced  by  the  extent  to  which 
such  vivid  ideas  can  be  inhibited,  and  their  tendency  to  action 
delayed  or  averted,  than  by  their  immediate  translation  into  violent 
movement.  In  other  words,  inhibition  is  more  indicative  of  a 
strong  will  than  is  initiation.  Or  strength  of  will  is  more  manifest 
by  sustained  conduct  in  a  particular  direction  and  towards  a 
definite  end  than  by  the  immediate  and,  it  may  be,  violent  response 
to  the  feelings  and  emotions  of  the  moment.  Such  inhibition  must 
be  regarded  as  due  to  the  degree  of  attention  which  can  be  brought 
to  bear  upon  ideas  of  an  opposing  nature  until  they  acquire  suffi- 
cient dominance  to  neutralize  the  original  incentive  to  action.  If 
this  latter  is  of  an  antisocial  or  immoral  nature,  the  result  is  a 
great  moral  victory,  and  the  state  of  mind  which  occurs  whilst  the 
battle  is  being  fought  has  been  utilized  as  subject-matter  by  many 
novelists.  It  may  be  stated  that  the  performance  of  the  act  gives 
rise  to  an  emotional  state  which  is  either  pleasant  or  unpleasant, 
the  memory  of  which  may  serve  to  reinforce  or  neutralize  a  similar 
motor  idea  when.it  is  again  presented  to  consciousness.  In  this 
way,  by  bitter  experience,  the  child  learns  to  inhibit  action,  and 
so  develops  control  and  strength  of  will. 

Perhaps  these  remarks  may  help  us  to  understand  better  the 
varieties  of  defective  will  which  occur  in  aments.  Such  a  defect 
is  exceedingly  common,  and  I  think  that,  on  the  whole,  what  is 
usually  called  the  weakness  of  will  of  these  persons  may,  for 
purposes  of  description  at  any  rate,  be  divided  into  two  categories, 
according  as  it  is  chiefly  dependent  upon  a  paucity  of  ideas  or  a 
faulty  power  of  attention.  Thus  a  section  of  mentally  defective 
persons  are  placid,  stolid,  inert  individuals,  who  seem,  as  their 
friends  sometimes  say,  "  to  have  no  minds  of  their  own,"  and  who 
are  quite  content,  even  when  they  are  grown-up  men  earning  a 
regular  wage,  to  take  their  money  home  to  their  mothers,  and  receive 
in  exchange  an  occasional  penny  as  pocket-money.  The  defect 
here  seems  to  be  principally  one  of  general  brain  inertia,  in  conse- 


I20  Neuro-Physiology  and  Psychology 

quence  of  which  motor  ideation  does  not  attain  the  dominance 
necessary  for  action. 

Another  example  of  weakness  of  will  is  seen  in  those  feeble- 
minded girls  who  are  readily  amenable  to  the  sexual  suggestions 
of  any  man  they  may  chance  to  meet,  and  who,  in  the  absence  of 
supervision,  almost  inevitably  embark  upon  a  life  of  immorality 
and  petty  crime.  There  is  here  no  defect  of  motor  ideation,  and 
no  inability  to  recognize  that  their  acts  are  such  as  would  not  find 
favour  with  their  relatives  and  friends ;  but  ideation  from  internal 
stimuli  is  weak,  and  that  from  external  stimuli  more  ready,  there 
is  a  defect  of  attention,  and  no  power  for  mental  effort,  and  conse- 
quently a  complete  inability  to  withstand  the  temptation  of  the 
moment  and  consistently  to  follow  a  right  course  of  action.  Another 
example  of  weak  will  is  seen  in  the  intractable,  emotional,  and 
explosive  type  of  ament,  which  will  be  described  in  the  chapter 
dealing  with  mentally  deficient  criminals.  In  these  also  the  con- 
dition seems  to  be  largely  due  to  a  defect  of  attention,  possibly 
conjoined  with  an  excessive  instability  of  lower-level  brain  cells. 

Temperament. — Since  the  days  of  Aristotle  it  has  been  customary 
to  describe  four  temperaments — namely:  Choleric,  where  the 
excitability  is  great  and  after-effect  great;  sanguine,  where  the 
excitability  is  great  and  the  after-effect  small;  plilegmatic,  where 
the  excitability  is  small  and  after-effect  small ;  melancliolic,  where  the 
excitability  is  small  and  after-effect  great.  These  differences  are 
dependent  upon  physiological  peculiarities  of  nerve  action,  and 
the  mentally  defective  person  is  subject  to  physiological  differences 
in  the  same  way  as  the  normal,  although  some  types  are  much  more 
frequent  than  others.  In  general,  it  may  be  said  that  aments  are 
rarely  of  the  choleric  type ;  in  those  in  whom  there  is  great  initial 
excitability  the  effect  is  usually  transient,  so  that  they  come  within 
the  sanguine  group.  Many  are  phlegmatic,  and  a  few — chiefly  of 
the  feeble-minded  grade — are  melanchohc  in  their  temperamental 
reaction. 

Although  most  aments  will  display  a  childish,  and  at  tunes  keen, 
interest  in  spectacular  displays,  they  are  not  as  a  i-ule  aroused 
thereby  to  the  same  pitch  of  enthusiasm  as  a  normal  child.  More- 
over, the  impression  quickly  fades,  and  they  soon  cease  to  talk 
about  it.  Although  by  no  means  insensible  to  praise  or  blame, 
pleasure  or  punishment,  they  are  not  as  a  rule  greatly  affected 
thereby,  and  the  sensation  is  but  fleeting.     Some  of  the  milder 


Cerebration  i  2 1 

grades,  it  is  true,  evince  a  considerable  amount  of  mental  perturba- 
tion on  first  leaving  their  friends  for  the  care  of  strangers ;  but  they 
are  seldom  really  home-sick,  as  is  the  ordinary  child,  and  they  rapidly 
settle  down  to  their  new  surroundings  with  hardly  a  thought  of  the 
old.  Of  most  of  them  it  may  be  said  that  their  general  attitude 
is  one  of  placid  indifference,  and  that  they  are  decidedly  less 
affected  by  the  happenings  of  life  than  are  ordinary  people. 

A  few  may  be  described  as  sanguine.  They  are  quick,  lively, 
and  readily  attracted  by  anything  happening  around  them,  and 
easily  moved  to  laughter  or  tears,  passionate  anger,  or  cloudy  sullen- 
ness.  But  this  state  is  very  fleeting,  and  leads  to  little  result. 
Though  seemingly  full  of  interest  in  everything,  they  settle  down 
to  nothing.  Another  small  proportion  belong  to  the  melancholic 
type.  In  these,  although  censure,  punishment,  or  neglect  seem  to 
make  little  impression  at  the  time,  the  child  or  adult  becomes 
morose,  and  begins  to  brood  over  his  real  or  fancied  wrongs.  Some- 
times a  state  of  true  melancholia  results,  and  I  have  known  several 
persons  of  this  type  who  have  attempted  suicide. 

Emotion. — It  seems  probable  that  every  sensation  is  accom- 
panied by  an  affective  tone  or  "  feeling,"  which,  generally  speaking, 
is  of  a  pleasant  or  unpleasant  nature  according  as  the  sensation 
tends  to  be  conservative  or  inimical  to  the  individual  or  race. 
With  the  development  of  ideation,  however,  simple  feelings  of  this 
kind  acquire  a  much  more  complex  character,  and  constitute  those 
affective  brain  states  with  which  we  are  all  famihar,  and  which 
are  termed  "  emotions."  The  number  of  them  is  practically  end- 
less, embracing  as  they  do  such  as  fear,  anger,  disgust,  hate,  con- 
tempt, joy,  gratitude,  contentment,  hope,  sorrow,  despair,  resig- 
nation, horror,  envy,  jealousy,  regret,  misery,  pride,  shame,  together 
with  hunger,  acquisitiveness,  philoprogenitiveness,  and  very  many 
others. 

Without  going  into  the  vexed  psychological  question  as  to  which 
comes  first — that  is,  as  to  whether  the  emotion  precedes  the  ex- 
pression of  it  or  the  expression  itself  gives  rise  to  the  emotion — 
there  can  be  no  doubt  that  the  capacity  for  experiencing  the  various 
emotions  is  inseparably  bound  up  with  the  capacity  for  ideation, 
and  hence  where  this  latter  is  defective,  as  in  aments,  the  varieties 
of  emotion  experienced  will  be  similarly  defective  in  both  quantity 
and  quality.  As  the  old  adage  has  it,  "  Where  there  is  little  sense, 
there  is  httle  feeling,"  and  we  find  that  the  capacity  for  experiencing 


122  Neuro-Physiology  and   Psychology 

emotion  in  these  persons  is  usually  proportionate  to  the  amount  of 
general  intelligence  present,  although  something  seems  to  depend 
upon  the  particular  variety  of  nervous  temperament.  In  the 
absolute  idiots  there  seems  to  be  neither  feeling  nor  emotion. 
Those  above  this  grade  seem  to  be  capable  of  experiencing  sensa- 
tions of  hunger,  thirst,  and  the  general  pleasantness  or  unpleasant- 
ness of  their  surroundings.  Imbeciles  are  capable  of  feeling, 
amongst  others,  affection,  grief,  fear,  anger,  surprise,  hate,  and 
possibly  envy  and  jealousy;  whilst  the  feeble-minded  show  evidence 
of  such  more  complex  emotions  as  shame,  awe,  contempt,  disgust, 
indignation,  and  the  like.  It  is  to  be  remarked,  however,  that 
such  feelings  rarely  seem  to  have  the  same  intensity  as  they  do 
in  normal  persons,  and  that  they  are  usually  of  more  transient 
duration.  In  what  may  be  termed  the  "  emotional  type"  of 
ament,  it  seems  doubtful  whether  the  range  of  feeling  is  at  all  large, 
nor  is  its  intensity  to  be  necessarily  judged  by  the  violence  of  action 
which  may  accompany  it,  the  chief  characteristic  being  the  rapidity 
with  which  one  variety  of  feeling  gives  place  to  another  of,  it  may 
be,  an  exactly  opposite  character. 

Sentiment. — What  is  termed  "  sentiment  "  represents  a  higher 
development  of  the  affective  state,  and  it  has  been  neatly  defined 
as  "an  organized  system  of  emotional  dispositions  centred  about 
the  idea  of  some  object."  In  the  main  we  may  describe  four 
varieties  of  sentiments  or  senses — namely,  intellectual,  cesthetic, 
moral  or  social,  and  religious.  The  intellectual  or  logical  sense, 
which  causes  us  to  test  each  new  experience  by  the  light  of  our 
previous  knowledge,  is  essentially  wanting  in  aments.  The  cBSthetic 
sense,  which  connotes  an  appreciation  of  beauty  as  opposed  to 
ugliness,  is  seldom  present  to  any  considerable  extent,  although  it 
is  not  infrequently  present  in  a  rudimentary  form.  Some  mild 
aments,  however,  may  possess  it  to  a  very  extraordinary  degree,  as 
is  shown  by  marked  musical  or  artistic  talent.  The  moral,  ethical, 
or  social  sense  is  the  faculty  of  appreciating  the  obligations  due  from 
man  to  his  neighbours  as  component  parts  of  society,  and  which 
causes  a  person  to  ask.  Is  this  right  or  wrong  ?  This  sense  is,  of 
course,  lacking  in  idiots  and  imbeciles,  and  in  the  feeble-minded  it 
rarely  reaches  a  high  degree  of  development.  Most  of  these  persons 
act  upon  the  impulse  of  the  moment,  quite  unaffected  by  any 
altruistic  feelings.  They  may  develop  the  habit  of  refraining  from 
lying  or  pilfering  because  they  realize  that  such  leads  to  punish- 


Action  123 

ment,  but  the  majority  do  not  understand  that  any  obligation  is 
morally  due  from  them,  or  that  they  should  be  virtuous  for  virtue's 
sake.  At  the  same  time,  some  certainly  do  acquire  rudimentary 
ideas  of  unselfishness  and  good  behaviour.  The  religious  sense 
connotes  a  feeling  of  the  relationship  between  God  and  man.  I 
think  the  germ  of  this  is  often  present  in  the  milder  aments,  and 
not  a  few  of  them  develop  hazy,  anthropomorphic  ideas  of  a 
Supreme  Being.  They  may  be  taught,  and  in  a  simple  way  under- 
stand, the  Bible  stories;  they  may  tell  one  that  after  death  the 
good  people  go  to  heaven  and  the  bad  ones  to  hell,  and -this  belief 
may  be  not  without  effect  upon  their  daily  behaviour;  but  of 
theological  dogma  or  doctrine  beyond  this  the  majority  have  little 
or  no  conception. 

ACTION. 

All  sensations  tend  to  movement,  and  it  is  by  movement,  in 
some  form  or  other,  that  the  existence  of  mind  is  made  manifest. 
Observation  of  movement,  therefore,  as  occurring  in  the  ordinary 
contractions  of  the  body  muscles,  in  the  more  complicated  mechan- 
ism of  speech,  or  in  the  still  more  complicated  actions  by  which  the 
individual  reacts  to  his  surroundings,  known  as  "  behaviour  "  and 
"  conduct,"  constitutes  the  means  by  which  we  judge  of  the  quantity 
and  quality  of  his  mind.  This  relationship  has  been  ably  pointed 
out  by  Dr.  Francis  Warner,*  and  to  this  author  we  are  indebted  for 
much  valuable  information  regarding  anomalies  of  motor  function, 
or,  as  he  terms  them,  "  abnormal  nerve  signs,"  in  the  mentally 
defective. 

Movement. — The  simplest  form  of  movement  is,  in  all  probability, 
the  result  of  explosions  within  the  motor  ganglion  cells  taking  place 
in  consequence  of  their  own  inherent  instability.  Such  movement 
is  spontaneous,  and  is  seen  in  the  spreading  of  the  fingers  and  toes 
of  the  young  infant  (the  "  microkinesis  "  of  Warner) ;  later,  possibly, 
in  the  inarticulate  babblings  and  cooings  which  denote  the  first 
activity  of  the  motor  cells  concerned  in  speech.  Presently,  as  a 
result  of  the  laying  down  of  pathways  within  the  cerebral  mass,  the 
motor  cells  acquire  two  connexions.  One  of  these  brings  them  into 
relation  with  the  sensory  areas  of  the  brain,  the  other  with  the 
higher  levels  concerned  in  ideation  and  volition.     As  a  result  of 

*  Francis  Warner,  "  Anatomy  of  Movement,"  "  Mental  Faculty,"  and 
numerous  other  writings. 


1  24  Neuro-Physiology  and  Psychology 

the  former  of  these  connexions,  the  simple  spontaneous  movements 
become  so  modified  and  controlled  by  the  quantity  and  quality  of 
the  incoming  sensations  as  to  be  perfectly  adapted  to  them.  We 
then  have  a  co-ordinated  movement,  in  which  an  optimum  result 
takes  place  with  a  minimum  expenditure.  When  this  result  has 
been  attained,  and  a  well-worn  pathway  established  between  sensory 
and  motor  areas,  the  appropriate  movement  is  readily  called  forth 
upon  the  presentment  of  its  customary  stimulus,  producing  a  reflex 
co-ordinated  action.  Many  of  the  ordinary  reflex  movements  are 
the  result  of  spinal  rather  than  cerebral  action. 

The  new-born  child  comes  into  the  world  with  some  of  these 
channels  already  laid  down,  so  that  it  is  capable  of  so-called  instinc- 
tive or  hereditary  movements,  such  as  grasping,  sucking,  and  crying. 
If  an  adult's  fingers  be  placed  within  the  grasp  of  a  new-born  child, 
it  closes  on  them  so  tightly  that  he  can  be  lifted  off  the  bed  without 
letting  go.  This  is  purely  instinctive,  and  passes  off  a  few  days 
after  birth. 

The  second  connexion,  which  links  up  the  motor  cells  with  those 
portions  of  the  brain  concerned  with  the  intellectual  processes, 
brings  the  motor  functions  under  the  influence  of  the  will,  and  so 
makes  volitional  action  possible.  Such  action  is  always  preceded 
by  an  idea  of  the  motion  to  be  performed  (motor  idea) .  The  nature 
of  this  volitional  action,  however,  will  be  different  according  as 
other  intellectual  associations  act  as  a  drag  or  not  upon  immediate 
response.  In  the  simplest  and  lowest  type  of  mind  an  immediate 
response  follows  the  presentment  of  the  idea,  and  the  action  is 
impulsive.  Such  may  take  place  almost  with  the  rapidity  of  a 
reflex  act ;  indeed,  by  constant  repetition  the  motor  idea  to  an  action 
of  this  kind  may  be  subconscious,  and  the  action  truly  reflex. 
On  the  other  hand,  the  motor  idea  may  call  up  other  associates, 
so  that  deliberation  intervenes  to  delay  or  inhibit  the  natural 
tendency  to  immediate  action.  After  a  longer  or  shorter  period  of 
deliberation,  in  which  the  pros  and  cons  are  carefully  passed  in 
review,  a  choice  is  made,  and  finally  the  highest  t^'pe  of  action — a 
deliberate,  purposeftd  manifestation  of  will — results. 

We  thus  see  that  in  aments  various  anomalies  of  movement  may 
occur  as  a  result  of  their  imperfection  of  development.  The  meta- 
bolism or  excitability  of  the  motor  ganglion  cells  may  be  abnormal, 
and  the  qiiantity  of  movement  defective  or  excessive.  Sensations 
may  be  imperfect  or  distorted,  or  the  connexions  between  sensory 


Action  125 

and  motor  areas  faulty,  leading  to  defects  in  the  quality  of  move- 
ment or  inco-ordination.  The  connexions  between  sensory  and 
motor  centres  which  are  normally  laid  down  at  birth  may  be 
lacking,  producing  a  diminution  or  absence  of  the  instinctive  move- 
ments— a  condition  which  is  by  no  means  infrequent  in  idiocy. 
On  the  volitional  side  response  may  occur  immediately  upon  pre- 
sentment of  the  idea,  and  impulsive  action  of  this  kind  is  very 
characteristic  of  many  aments.  On  the  other  hand,  response  may 
be  tardy,  not  because  of  the  intervention  of  deliberation,  but  be- 
cause the  cerebral  cells  generally  are  lethargic  and  unexcitable, 
and  the  connexion  between  volitional  and  motor  centres  a  com- 
paratively untrodden  pathway;  and  this  kind  of  slothful  action  is 
characteristic  of  another  type  of  aments.  Finally,  anomalies  of 
movement  may  occur  in  consequence  of  gross  lesions  or  disease  of 
the  cerebro-spinal  axis.  We  may  now  consider  the  chief  of  these 
anomalies  of  the  motor  functions  somewhat  more  in  detail. 

Deficient  Movement. — In  a  considerable  number  of  aments  move- 
ment is  deficient  in  quantity,  and  this  is  generally  the  result  of  a 
diminished  excitability  of  the  nerve  cells.  The  condition  is  most 
common  in  the  severest  grade,  but  it  is  also  seen  in  the  imbeciles 
and  feeble-minded.  In  the  most  pronounced  cases  it  is  obvious 
from  birth,  and  the  child  never  cries,  sucks,  or  looks  about  him  like 
an  ordinary  child;  in  the  milder  forms  these  instinctive  movements 
are  present,  but  the  child  is  backward  in  his  first  attempts  at  sitting 
up,  standing,  and  walking,  whilst  speech  is  very  much  delayed. 
The  appearance  of  such  children  is  usuallj^  characteristic;  the  face 
wears  a  dull,  heavy,  vacuous  expression,  and  there  are  many 
indications  of  want  of  muscular  tone.  In  the  temporal  and  masseter 
muscles  this  often  shows  itself  by  dropping  of  the  lower  jaw  and  a 
persistently  open  mouth.  Continuous  slavering  is  very  common 
in  such  cases.  The  general  balance  of  the  body  is  feeble,  and  when 
the  child  walks,  he  does  so  with  a  slothful  clumsiness.  If  told  to 
follow  an  object  with  his  eyes,  he  either  makes  no  response  or  turns 
his  whole  head  round  in  a  slow  and  laboured  manner.  His  arms 
are  listlessly  extended  to  command,  but  the  fingers  and  hands  hang 
flabbily  down,  and  the  whole  arm  very  soon  drops  to  the  side.  His 
whole  appearance  and  behaviour  are  indicative  of  cerebral  and 
spinal  inertia. 

Excessive  Movement. — In  another  type  of  aments  all  movement 
is  in  excess,  and  the  condition  is  one  of  chattering,  ceaseless  activity. 


126  Neuro-Physiology  and   Psychology 

This  also  is  noticeable  soon  after  birth,  and  the  remark  is  often  made 
by  the  parents  that  the  child  "  never  sleeps."  This  of  course,  is 
not  really  the  case ;  for  although  these  children  do  not  have  regular 
long  periods  of  sleep  like  ordinary  children,  or  even  ordinary  idiots, 
there  is  no  doubt  that  they  do  have  brief  but  frequent  snatches. 
There  is  equally  no  doubt,  however,  that  their  sleep  is  very  light 
and  readily  disturbed.  This  condition  is  the  antithesis  of  the  one 
just  described,  and  is  due  to  hyper-excitability  of  nervous  tissue. 
For  some  time  after  birth  it  is  manifested  as  an  excess  of  spon- 
taneous movement,  but  as  the  motor  cells  acquire  connexions 
with  sensory  and  ideational  areas,  this  type  of  movement  alters, 
being  replaced  by  actions  of  a  higher  order.  Of  these  there  are 
three  chief  forms — namely,  ideo-motor  repetitive  actions  of  sub- 
conscious type ;  ideo-motor  repetitive  actions  of  conscious  type ;  and 
impulsive  volitional  actions.  It  is  to  be  remarked  that,  although 
these  varieties  of  excessive  movement  are  very  common  in  amentia, 
they  are  not  characteristic  of  that  condition,  but  may  occur  in  a 
merely  neurotic  child.  Most  of  these  forms  of  excessive  movement 
are  accompanied  by  a  diminished  capacity  for  sustained  attention, 
and  this  is  well  seen  in  the  restless  ament  whose  attention  is  so 
distracted  by  every  sight,  sound,  or  feeling  reaching  his  sensorium 
that  steady  continuous  work  becomes  an  impossibility. 

In  a  considerable  number  of  aments  excessive  action  is  chiefly 
pronounced  in  certain  groups  of  muscles,  and,  by  being  constantly 
repeated,  the  movements  acquire  an  automatic  and  subconscious 
character.  They  are  then  popularly  known  as  tricks  or  habits. 
The  most  frequent  of  these  are  spasmodic  frowning  and  knitting  of 
the  eyebrows  (which  may  be  symmetrical  or  unilateral),  grinning, 
smiling,  and  grimacing;  nodding  and  shaking  of  the  head;  shrug- 
ging of  one  or  both  shoulders;  opening  and  shutting  of  the  hands, 
and  swaying  of  the  body;  biting  the  nails,  sucking  the  thimib,  and 
many  others  of  like  character.  The  characteristic  of  these  move- 
ments is  that,  at  first  irregular,  they  subsequently  tend  to  be 
repeated  at  more  or  less  regular  intervals,  and  are  particularly 
marked  when  the  child  is  in  the  presence  of  strangers  and  conscious 
that  he  is  being  observed ;  further,  unlike  the  spasmodic,  purposeless 
movements  of  chorea,  they  are  definite  co-ordinated  acts.  Originally 
it  is  probable  that  many  of  them  had  a  purpose ;  for  instance,  I  have 
sometimes  traced  the  repeated  shaking  of  the  head,  which  is  very 
commonly  seen  in  neurotic  children,  to  the  presence  of  long,  strag- 


Action 


127 


gling  hair  hanging  in  front  of  the  eyes.  The  frequent  repetition 
of  the  act  produces  in  time  a  kind  of  obsession,  and  this  leads  to 
its  automatic  unconscious  performance  when  the  original  cause  has 
been  removed.     In  aments  it  often  lasts  throughout  life. 

Closely  related  to  these  automatic  actions  are  others  of  a  some- 
what higher  character,  inasmuch  as  they  are  always  voluntarily 
performed.  Dr.  John  Thomson*  enumerates  the  chief  of  these  as 
pica,  or  dirt-eating,  sucking  the  tongue,  thumb,  etc.,  biting  the 
nails,  head-rolling,  head-banging,  rocking  and  swaying  movements 
of  the  body,  and  masturbation.  Dr.  Thomson  says  that  "  the 
normal  act  causes  little  pleasure  to  the  healthy  child,  whilst  its 
morbid  counterpart  has  an  extraordinary  fascination  for  the 
children  who  practise  it.  .  .  .  The  essential  character  which  serves 
at  once  to  distinguish  these  habits  from  certain  motor  neuroses 
{e.g.,  spasmus  nutans  and  habit  spasm),  which  some  of  them  super- 
ficially resemble,  is  their  deliherateness.  The  child's  will  is  im- 
plicated; and  what  he  does  is  done  intentionally — at  first,  at  least — 
because  he  likes  doing  it.  They  have  a  strong  tendency  to  occur 
when  the  patient  is  feeling  dull  and  not  being  interested  by  his 
surroundings.  They  are  almost  always  stopped  when  the  child's 
attention  is  taken  up  with  anything  that  interests  him." 

Finally,  another  iy^Q  of  excessive  movement  is  seen  in  the  im- 
pulsive volitional  actions  which  are  of  such  frequent  occurrence  in 
certain  mental  defectives.  With  these  persons,  an  idea  is  no  sooner 
presented  than  it  is  acted  upon,  quite  regardless  of  right  or  wrong 
or  possible  consequences.  Many  of  them  belong  to  the  milder 
degrees  of  amentia,  and  some  are  by  no  means  unintelligent;  but 
their  whole  life  is  actuated,  not  by  intelligence,  but  by  impulse. 
The  essential  basis  seems  to  be  an  undue  motor  excitability,  and  the 
defective  deliberation  and  control  allow  this  to  have  free  play. 
They  comprise  the  "  unstable  "  type  of  aments,  of  whom  more  will 
be  said  in  subsequent  chapters. 

Inco-ordinaie  Movement. — Co-ordination,  in  the  wide  meaning  of 
the  term,  requires  a  series  of  motor  explosions  which  are  regular  in 
time,  degree,  and  sequence,  as  well  as  in  their  harmonious  adaptation 
to  the  various  sensory  stimuli  concerned  in  the  movement  per- 
formed, particularly  those  coming  from  the  muscles.  It  is  therefore 
dependent  upon  perfectly  working  sensory,  commissural,  and  motor 

*   John   Thomson,    "  On   Certain   So-called    '  Bad   Habits  '   in   Children," 

Archives  of  Pediatrics,  April,  1907. 


128  Neuro-Physiology  and  Psychology 

mechanisms;  but  even  where  these  exist,  as  in  the  normal  child, 
perfect  co-ordination  is  only  attained  by  constant  practice. 

In  persons  suffering  from  even  the  mildest  degree  of  amentia, 
co-ordination  is  often  acquired  with  difficulty,  and  remains  imper- 
fect; and  although  many  of  them  may  learn  to  use  their  hands 
with  a  considerable  amount  of  dexterity,  the  balance  and  move- 
ment of  the  body  often  continue  clumsy  and  ungainly.  It  is  fre- 
quently years  before  the  mentally  defective  child  manages  to  lace 
his  boots,  button  his  clothes,  or  manipulate  his  spoon  at  table. 
Even  the  best  of  them  (with  a  few  remarkable  exceptions)  rarely 
attain  to  the  precision  and  neatness  of  movement  of  which  an 
ordinary  well-trained  child  is  capable. 

In  the  lower  degrees  the  defect  is  still  more  marked,  and  many 
imbeciles  experience  the  greatest  difficulty  in  picking  up  a  pin 
or  a  coin,  and  are  incapable  of  any  but  the  coarsest  movements. 
Dr.  Ireland  remarks  that  considerably  more  imbeciles  than  normal 
people  are  ambidextrous;  but  I  think  it  is  not  that  both  hands  are 
used  equally  well,  but  rather  equally  badly,  and  I  should  prefer 
to  say  that  they  were  a-dextrous.  Many  of  their  defects  of  speech 
are  due  to  imperfect  muscular  co-ordination. 

An  extremely  delicate  test  of  the  degree  of  control  over  muscular 
action  is  afforded  by  the  "  transfer  "  and  "  imitation  "  movements 
of  Dr.  Warner.  In  performing  imitation  movements,  the  child 
stands  a  little  distance  in  front  of  the  observer,  who  performs  a 
series  of  extensions,  flexions,  and  other  movements  with  his  own 
arm,  forearm,  hand,  and  finally  individual  digits,  each  of  which 
the  child  must  imitate  as  it  is  performed.  In  the  transfer  move- 
ments the  child  stands  with  closed  eyes  and  extended  hands.  The 
observer  then  performs  passive  movements  upon  the  digits,  etc., 
of  one  limb  of  the  child,  who  is  required  to  make  corresponding 
movements  with  the  other.  Dr.  Warner  tells  me  that  he  considers 
these  tests  to  be  extremely  delicate,  and  that  even  in  a  healthy 
person  slight  imperfections  may  be  observed  as  the  result  of  fatigue. 

Finally,  it  may  be  remarked  that  anomalies  of  movement  due 
to  localized  or  general  disease  of  the  brain  are  not  uncommon  in 
aments.  The  chief  of  these  are  nystagmus,  athetosis,  epileptiform 
and  epileptic  convulsions,  and  chorea;  but  they  do  not  differ  from 
similar  affections  in  the  mentally  sound. 

Speech. — The  subject  of  the  speech  of  aments  is  one  of  con- 
siderable interest  and  importance,  for  several  reasons.     In  the  first 


Speech  129 

place,  defects  of  speech  are  very  frequent,  and  their  examination 
affords  a  means  by  which  certain  sensory,  associative,  and  motor 
functions  may  be  conveniently  tested  and  recorded.  Further,  quite 
apart  from  its  mere  mechanism,  the  language  of  these  persons  is 
•one  of  the  most  valuable  means  we  have  of  gauging  their  stock  of 
ideas  and  the  general  capacity  and  nature  of  their  intellects ;  whilst 
in  the  milder  degrees  the  training  of  speech,  if  conducted  upon 
scientific  principles,  and  after  a  careful  study  of  the  needs  of  the 
individual,  is  a  very  important  means  of  improving  sensory  and 
motor  functions,  and  regulating  mental  action  generally. 

True  speech  is  not  merely  the  ability  to  utter  articulate  sounds : 
it  is  the  faculty  of  using  words  to  express  thoughts;  and  before 
this  can  take  place  certain  conditions  must  be  fulfilled.  These  are, 
firstly,  the  power  to  hear  sounds ;  secondly,  a  conscious  recognition 
of  the  object  or  idea  for  which  the  sound  heard  is  the  symbol; 
thirdly,  an  ability  to  reproduce  the  sound  as  the  expression  of 
the  same  object  or  idea.  It  is  thus  seen  that  the  faculty  of  speech 
is  composed  of  an  afferent  pathway  (normally  auditory,  although 
•exceptionally  other  sensory  channels  may  serve  instead,  as  in  lip 
reading),  with  its  prolongation  to  a  higher  conscious  station;  of  a 
connexion  between  this  conscious  station  and  the  motor  speech 
•centre ;  and  thence  an  efferent  pathway  to  the  muscles  concerned  in 
phonation  and  articulation.  In  addition,  there  is  good  reason  for 
thinking  that  a  more  direct  and  subconscious  connexion  exists 
between  the  sensory  and  motor  centres.  The  nervous  mechanism 
concerned  in  speech  may  therefore  be  represented  by  the  capital 
letter  A,  in  which  the  side-limbs  denote  the  afferent  and  efferent 
paths  respectively  to  and  from  consciousness,  and  the  cross-piece 
the  shorter  subconscious  connexion  between  the  sensory  and  motor 
■stations. 

In  the  normal  child  sounds  are  differentiated  in  the  early  months 
of  life,  but  it  is  not  until  he  is  nearly  a  year  old  that  he  begins  to 
associate  words  with  objects  and  ideas,  and  to  understand  what  is 
said  to  him.  At  this  age  he  has  still  little  command  over  the  motor 
speech  centre,  the  first  evidence  of  activity  in  which  consists  of 
cooing  and  babbling  interjections  of  spontaneous  origin  similar  to 
the  incessant  small  movements  of  fingers  and  toes.  Presently, 
however,  owing  to  the  faculty  of  imitation,  these  irregular  sounds 
become  co-ordinated  into  copies  of  those  he  hears,  and  very  soon 
after  this  the  child  acquires  the  power  of  expressing  his  simple 

9 


130  Neuro- Physiology  and  Psychology 

thoughts  and  wants  by  articulate  speech.  After  this  progress  is 
usually  rapid,  and  during  the  third  year  the  child  may  possess  a 
vocabulary  of  several  hundred  words. 

In  the  ament  defects  of  speech  are  exceedingly  common,  probably 
being  present  to  some  extent  in  fully  three-quarters  of  all  cases. 
In  these  persons  the  advent  of  speech  is  nearly  always  delayed,  even 
the  first  indications  of  activity  of  the  motor  cells,  which  normally 
appear  during  the  third  or  fourth  month,  not  being  noticed  until 
much  later,  and  the  customary  babbling  is  very  often  absent  in 
the  mentall}'  defective  child.  It  may  be  five,  six,  or  even  more 
years  before  the  mentally  deficient  child  gives  utterance  to  sl 
definite  word  as  the  expression  of  an  idea.  In  the  severest  grades 
of  mental  defect  the  faculty  is  never  developed,  and  the  majority 
of  idiots  are  incapable  of  articulating  a  single  word.  Others  of  this 
degree  can  say  a  few  monosyllables,  such  as  "  man,"  "  cat,"  but 
none  of  them  are  capable  of  forming  sentences.  In  the  imbecile 
speech  is  usually  present,  and  he  is  able  to  understand  and  speak 
short  sentences;  but  his  vocabulary  is  small,  and  his  utterance 
often  almost  uninteUigible  owing  to  faulty  articulation.  In  the 
feeble-minded  degree,  imperfections  of  utterance  tend  to  be  some- 
what less,  and  the  vocabulary  considerably  more  extensive;  but 
these  persons  are  usually  neither  capable  of  forming  nor  understand- 
ing a  sentence  at  all  complicated  in  its  construction. 

It  is  thus  seen  that  on  the  whole  there  is  a  tolerably  close  rela- 
tionship between  the  capacity  for  speech  and  the  degree  of  mental 
defect,  and  this  led  Esquirol  to  suggest  the  use  of  this  faculty  as  a 
means  of  classification.  But  to  this  there  are  many  exceptions: 
some  quite  low-grade  imbeciles  are  possessed  of  exceedingly  good 
articulation  and  fluent  speech,  whilst  a  small  number  of  the  feeble- 
minded are  limited  in  their  utterance  to  a  few  words,  and  even  these 
may  be  almost  uninteUigible.  The  remarkable  genius  of  Earls- 
wood  Asylum,  of  whom  a  description  will  be  given  in  a  subsequent 
chapter,  is  an  excellent  example  of  this  latter  class.  It  is  true  that: 
those  imbeciles  whose  speech  is  so  fluent  often  have  little  or  even 
no  idea  of  the  meaning  of  the  poetrj^or  sentences  they  so  glibly  repeat,, 
and  it  is  quite  open  to  question  whether  their  articulator}^  capacity 
properly  comes  within  the  strict  meaning  of  the  term  "speech."  But 
even  apart  from  this,  I  am  of  opinion  that  there  is  no  such  constant 
relationship  between  wealth  of  ideas  and  capacity  of  expressing 
them  as  would  justify  us  in  accepting  speech  as  a  means  of  differ- 


Speech  1 3 1 

entiation;  and  the  physician  must  be  upon  his  guard  against  judging 
of  the  degree  of  mental  deficiency  by  the  amount  of  speech. 

In  cases  where  there  is  no  deafness,  and  speech  is  markedly 
deficient,  it  is  highly  probable  that  some  degree  of  mental  defect  is 
present,  and  delayed  speech  is  often  one  of  the  first  signs  to  attract 
the  parents'  attention,  and  to  cause  professional  advice  to  be  sought ; 
but  as  an  indication  of  the  amount  of  defect,  the  general  behaviour 
under  examination  is  often  of  far  more  importance  than  is  speech. 

Defects  of  speech  may  be  due  to  anomalies  of  the  sensory,  motor, 
or  intellectual  (association)  pathways;  but  in  most  cases  it  is  the 
two  latter  which  are  chiefly  at  fault.  Sensory  defects  may  be 
auditory,  causing  an  imperfect  perception  of  sounds;  or  they  may 
concern  the  tactile  and  muscular  sensations  coming  from  the  tongue 
and  lips  during  the  act  of  articulation.  It  has  already  been  re- 
marked that  the  range  and  delicacy  of  the  sensorium  of  the  ament 
is  often  diminished,  and  in  a  few  more  or  less  actual  deafness  is 
present.  I  do  not  think,  however,  that  imperfection  of  hearing 
proper  plays  a  very  important  part  in  the  defective  speech  of  these 
persons. 

Anomalies  of  the  motor  mechanism  are  much  more  frequent,  and 
these  comprise  imperfections  of  the  cortical  speech  centre,  or  of  the 
end  organs  concerned  in  the  production  of  voice  and  speech.  With 
regard  to  central  defects,  pure  motor  aphasia  is  rare;  but  one  boy, 
who  was  under  my  care  for  several  years,  was  a  perfect  example  of 
this  condition.  In  this  case  there  was  at  times  considerable  in- 
attention ;  but  the  boy  had  no  loss  of  hearing,  and  could  understand 
and  obey  commands  perfectly  well.  He  could  also  make  grunting 
and  other  inarticulate  noises,  but  the  only  approach  to  a  word 
which  we  could  get  him  to  say  after  years  of  training  was  "  Cuckoo." 
This  case,  however,  was  one  of  secondary  and  not  primary  amentia, 
and  resulted  from  an  attack  of  encephalitis  in  the  early  months  of 
life.  Another  and  much  more  common  cortical  anomaly  is  the 
want  of  co-ordination  which  results  in  stuttering  and  stammering. 
Peripheral  deficiencies  are  exceedingly  numerous,  and  the  whole 
character  of  the  voice  and  speech  may  be  profoundly  altered  by 
deformities  of  the  tongue,  lips,  teeth,  and  palate,  as  well  as  by 
enlarged  tonsils  and  adenoids.  These,  however,  are  relatively  un- 
important, as  they  only  give  rise  to  peculiarities  of  articulation. 
I  doubt  whether  shortness  of  the  frsenum  linguae  ("  tongue-tied  ") 
can  ever  be  considered  a  cause  of  delayed  or  even  imperfect  utter- 


132  Neuro-Physiology  and  Psychology 

ance.  Aphonia,  in  which  the  voice  is  so  low  that  it  can  hardly  be 
heard  at  all,  may  be  due  to  either  central  or  peripheral  defects  of 
the  motor  mechanism. 

Defects  of  pronunciation  are  exceedingly  common  in  even  the 
mildest  grades  of  amentia,  and  are  attributable  to  imperfect  co- 
ordination or  to  lalling  and  lisping.  It  is  not  usual  to  find  any 
marked  impairment  of  the  vowel  sounds,  the  chief  imperfections 
being  noticed  in  the  consonants.  The  physiological  alphabet  of 
Wyllie*  forms  the  basis  upon  which  many  interesting  observations 
have  been  made  in  recent  years,  amongst  which  those  of  Dr.  Henry 
Ashbyf  and  Dr.  LapageJ  deserve  particular  mention.  To  this 
latter  inquirer  we -are  indebted  for  a  most  careful  research  into  the 
consonantal  defects  of  the  feeble-minded  child,  and  the  following 
table  is  to  a  great  extent  compiled  from  his  work.     In  this  table  the 


TABLE  VIII. 

Consonantal  Defects. 


Consonant. 

Commonly 
replaced  by 

As  in 

[     I.  Th 

ForT 

Fumb,  tee/,  mou/,  iank. 

2.  R 

YorL 

Yabbit  or  /abbit,  pa/tot. 

3-  Y 

R  or  L 

Z-ellow. 

4.  S 

T  or  Ts 

Tissors,  fooap. 

Most 

5.  G 

6.  Ng 

D 

Dun,  d.od,  surfar. 

frequently 

• 

D 

String. 

defective 

7.  Sh 

Tsh  or  T 

Tsheep,  Tsh\id3.v,  Tirt. 

8.  K 

T 

Tat,  toat,  bla^ 

9.  V 

B 

Belbet. 

10.  L 

Y 

Yeg,  yad. 

1    II.  F 

T 

Tottee. 

12.  Z 

Dse 

Norfse. 

13.  w 

M    (or 
omitted) 

Mindow. 

Less 

14.  p 

Tor  D 

Dac^er. 

frequently 

' 

15.  N 

D 

Tose,  Ved,  Teddy. 

defective 

16.  D 

T 

Toot,  lat. 

17.  T 

D 

Deef. 

18.  M 

B 

J&b. 

I    19-  B 

P 

Pag. 

*  Wyllie,  "  Disorders  of  Speech,"  1904. 

t  Ashby,    "  Speech    Defects    in    Mentally    Deficient     Children,"    Medical 
Chronicle,  October,  1903- 
X  Lapage,  op.  cit. 


Speech  133 

consonants  are  placed  in  the  order  in  which  Dr.  Lapage  found  them 
most  frequently  defective,  the  sounds  commonly  substituted  also 
being  shown  (see  Table  VIII.). 

It  is  of  interest  to  compare  this  defective  power  of  pronunciation, 
which  is  so  common  in  aments,  with  the  marked  aptitudes  in  this 
respect  of  some  of  the  lowest  savages.  Darwin,  in  his  "  Voyage  of 
the  Beagle,"  relates  that  the  Fuegians  "  could  repeat  with  perfect 
correctness  each  word  in  any  sentence  we  addressed  to  them,  and 
they  remembered  such  words  for  some  time.  ...  All  savages 
appear  to  possess,  to  an  uncommon  degree,  this  power  of  mimicry. 
I  was  told  of  the  same  ludicrous  habit  among  the  Caffres ;  the  Aus- 
tralians, likewise,  have  long  been  notorious  for  being  able  to  imitate 
and  describe  the  gait  of  any  man,  so  that  he  may  be  recognized." 
As  will  be  seen  in  speaking  of  idiots  savants,  such  extraordinary 
powers  are  occasionally  present  in  aments;  but  they  are  the  excep- 
tion and  not  the  rule. 

The  disorders  of  speech  wliich  are  chiefly  due  to  commissural  and 
intellectual  defects  include  the  misapplication  of  words  and  the 
inability  to  recall  appropriate  words ;  whilst  it  is  only  to  be  expected 
that  where  ideas  are  few  the  vocabulary  will  not  be  extensive. 
Various  forms  of  agrammatism,  or  imperfection  in  the  grammatical 
arrangement  of  sentences,  occur,  sometimes  with  the  production  of 
sentences  of  a  most  extraordinary  character.  The  enunciation  of 
the  grown-up  ament  often  retains  much  of  the  character  of  child- 
hood, whilst  a  general  brain  inertia  (sometimes,  however,  a  timidity 
under  examination)  causes  speech  to  be  slurred,  hesitating,  in- 
distinct, and  at  times  almost  unintelligible.  As  Max  Miiller  re- 
marks, correct  and  distinct  speech  requires  a  definite  mental  effort, 
and  of  this  many  aments  are  incapable. 

In  some  aments  the  condition  known  as  coprolalia,  or  "  filthy 
speech,"  exists.  This  is  a  more  or  less  sudden  outburst  of  language 
of  the  most  vile  and  disgusting  character,  and  it  is  remarkable 
that  it  often  occurs  in  persons  brought  up  amid  every  refinement. 
It  is  usually  accompanied  by  a  general  state  of  mental  excitement, 
for  which,  however,  no  cause  may  be  discoverable,  and  it  has  con- 
siderable analogy  to  the  motor  convulsions  of  the  epileptic.  It  is 
also  common  in  the  insane. 

Another  interesting  condition  which  is  occasionally  met  with  in 
the  mentally  defective,  although  by  no  means  confined  to  them,  is 
that  of  idioglossia.     This  is  really  a  more  extreme  form  of  lalling, 


T  34  Neuro-Physiology  and  Psychology 

but  the  consonantal  substitution  is  so  extensive  that  the  child 
appears  to  be  talking  a  totally  different  language  peculiar  to  him- 
self; hence  the  name. 

Finally,  mention  must  be  made  of  that  curious  speech  disturb- 
ance known  as  echolalia.  In  this  condition,  although  the  child  can, 
and  often  does,  use  words  to  express  his  ideas,  any  question  put  to 
him  is  followed,  not  by  a  reply,  but  by  its  repetition.-  Sometimes, 
after  repeating  the  question  once  or  twice,  the  child  will  answer  it ; 
but  in  other  cases  he  is  merely  repetitive,  and  often  copies  the  tone 
and  manner  of  the  questioner  with  remarkable  exactitude.  I 
recently  saw  a  mentally  defective  child  with  this  peculiarity,  whose 
parents  assured  me  he  could  speak  quite  sensibly,  and  yet  to  my 
questions  the  only  words  I  could  get  out  of  him  were,  "  What  is 
your  name?"  "Who  is  this?"  (pointing  to  his  mother),  "Shut 
the  door,"  and  similar  repetitions  of  every  question  or  command. 
This  condition  is  not  very  common,  and  is  somewhat  diflicult  to 
explain.  I  am  disposed  to  think  that  it  may  be  due  to  the  child's 
consciousness  being  so  swamped  or  occupied  (by  emotions  of  fright 
or  anxiety  in  some  cases  at  the  presence  of  a  stranger  or  unaccus- 
tomed surroundings)  that  auditory  sounds  only  reach  a  subconscious 
motor  idea  centre,  and  are  thence  immediately  translated  into 
speech.  There  is,  in  fact,  a  short-circuiting  of  the  nerve  current. 
This  condition,  as  far  as  I  am  aware,  does  not  occur  in  persons  of 
normal  mental  development,  although  it  is,  of  course,  b}^  no  means 
uncommon  for  a  person  to  speak  who  is  totaUy  unconscious  of 
his  surroundings.  Many  normal  children,  whilst  busily  engaged 
in  some  occupation,  will  repeat  words  which  are  pronounced 
near  them,  without  seemingly  understanding  the  words  or  being 
at  all  aware  of  the  fact  that  they  have  copied  them.  It  is  pre- 
sumably by  a  similar  subconscious  mechanism  that  echolalia 
occurs. 

It  has  already  been  mentioned  that  some  aments  have  an  extra- 
ordinary faculty  for  repeating  sounds  with  extreme  accuracy.  This 
ranges  from  the  humming  of  a  tune  to  the  repetition  of  poetry  or 
sentences  in  an  entirely  unknown  tongue.  The  subject  will  be 
again  aUuded  to  under  Idiots  Savants,  but  it  is  worthy  of  passing 
mention  in  this  place. 

Word  Blindness  and  Word  Deafness. — We  may  here  refer  to  a 
form  of  disorder  which,  until  the  last  few  years,  has  attracted  but 
httle  attention,  but  which  nevertheless  in  all  probability  occurs 


Word  Blindness  and  Deafness  135 

with  considerable  frequency.  Dr.  C.  J.  Thomas,*  indeed,  to  whom 
we  are  indebted  for  the  fullest  account,  considers  that  one  child  out 
■of  every  2,000  non-mentally  defective  school-children  is  word  blind, 
whilst  amongst  mentally  defective  children  the  proportion  rises  to 
as  much  as  one  in  twenty.  The  act  of  reading  is  dependent  upon 
printed  words  being  perceived  as  the  symbols  of  particular  ideas 
■or  objects.  This  process  is  a  cortical  one,  and  is  subserved  by  an 
area  of  the  temporal  lobe.  A  defect  of  this  area  does  not  interfere 
with  ordinary  vision,  but  it  may  render  the  person  incapable  of 
recognizing  the  meaning  of  printed  or  written  words,  and  he  is  then 
said  to  be  word  blind.  Children  so  affected  may  be  not  only  intelli- 
gent, but  may  evince  considerable  ability  in  drawing,  manipulation 
and  even  arithmetic;  but  it  is  impossible  to  teach  them  to  read 
■even  words  of  one  syllable,  although  they  may  sometimes  know  the 
meaning  of  a  word  if  it  is  spelt  out  to  them.  The  word  deaf  are 
similarly  defective  in  the  power  of  relating  the  sounds  of  words 
with  their  meaning,  although  there  is  no  deafness  in  the  ordinary 
way.  Such  children  can  write  from  a  copy  and  can  draw,  and  they 
may  understand  what  a  person  is  saying  by  watching  the  move- 
ment of  his  lips.  Indeed,  it  is  only  by  teaching  them  lip  reading 
that  there  is  any  possibility  of  their  learning  to  speak. 

Another  peculiarity  which  is  occasionally  found  in  aments,  and 
which  may  be  mentioned  here,  is  that  of  mirror-writmg,  so  called 
because,  instead  of  being  written  from  left  to  right  in  the  ordinary 
way,  the  writing  is  reversed,  and  must  be  placed  in  front  of  a  mirror 
to  be  read.  The  condition  is  not  very  common,  and  the  explana- 
tion forthcoming  not  entirely  satisfactory.  I  recently  observed  a 
variation  of  this  peculiarity  in  an  imbecile  of  ten  years  old.  Upon 
giving  him  a  sentence  to  copy,  he  did  so  from  right  to  left  in  the 
usual  manner  of  mirror-writers,  but  all  the  letters  except  one  were 
formed  in  the  proper  way,  so  that  the  production  ran  thus : 

rorriM  yliaD  ehT 

We  have  now  described  the  chief  defects  and  anomalies  of  mental 
and  nervous  action  which  occur  in  persons  suffering  from  amentia. 
It  need  hardly  be  said  that  they  comprise  a  catalogue  of  the  features 
•of  the  class  rather  than  a  picture  of  any  particular  member  of  that 

*  C.  J.  Thomas,  "  The  Aphasias  of  Childhood  and  Educational  Hygiene," 
1908. 


136  Neuro-Physiology  and  Psychology 

class,  and  it  is  essential  to  bear  in  mind  that,  although  all  mentally- 
defective  persons  resemble  one  another  in  the  fact  that  the  incom- 
plete state  of  their  minds  renders  them  incapable  of  so  adjusting 
their  conduct  as  to  maintain  existence  without  external  support, 
the  extent  to  which  they  are  thus  incapable,  the  degree  of  their 
accomplishments,  their  particular  psychological  failings,  and  what 
we  may  term  their  general  character,  are  subject  to  very  wide 
variations.  These  are  matters  which  will  be  dealt  with  when  we 
consider  the  various  clinical  types  in  subsequent  chapters. 


CHAPTER  VII 
THE  PHYSICAL  CHARACTERISTICS  OF  AMENTIA 

It  has  been  shown  that  the  great  majority  of  cases  of  amentia 
belong  to  the  primary  or  intrinsic  group,  being  the  result  of  a 
pathological  variation  of  the  germ  plasm.  In  a  few  cases  it  may 
happen  that  this  change  only  involves  that  portion  of  the  germ  cell 
concerned  with  the  development  of  the  central  nervous  system, 
which  we  may  designate  the  "  neuronic  determinant  " ;  the  develop- 
ment of  the  remainder  of  the  body  may  then  pursue  a  normal  course. 
In  most  cases,  however,  the  germinal  change  is  much  more  wide- 
spread. There  would  appear  to  be  an  im.pairment  not  merely  of 
the  neuronic,  but  of  many  other  determinants,  with  the  result  that 
the  whole  or  many  portions  of  the  body  are  marred  by  defects  of 
anatomical  development  and  physiological  function.  These  defects 
are  known  as  stigmata  of  degeneracy. 

In  recent  years  much  has  been  said  and  written  about  degeneracy, 
and  the  most  elaborate  tables  of  its  "  stigmata  "  have  been  com- 
piled. These  have  been  divided  into  social,  psychological,  physio- 
logical, anatomical,  and  other  groups,  and  some  writers  would  seem 
to  look  upon  any  departure  from  their  conception  of  what  is  or 
should  be  the  normal  social,  psychological,  physiological,  anatom- 
ical, or  other  condition,  as  a  "stigma  "  of  degeneracy.  I  do  not 
think  this  view  is  justifiable.  In  the  first  place,  there  are  so  many 
variations  within  healthy  limits  that  the  "  normal  "  becomes  ex- 
ceedingly difficult  to  define.  Moreover,  it  by  no  means  follows 
that  a  condition  which  is  uncommon,  or  even  "  abnormal,"  is  on 
that  account  a  mark  of  degeneracy,  or  that  it  is  even  pathological 
at  all.  We  have  not  yet  reached  finality,  and  manners,  morals, 
mind,  physiological  function,  even  anatomical  structure,  are,  we 
trust,  still  in  process  of  evolution ;  so  that  it  is  possible  for  some  of 
these  anomalies  described  as  "  stigmata"  to  be  not  retrogressive, 
but  actually  progressive. 

137 


138     The  Physical  Characteristics  of  Amentia 

But  even  where  they  are  undoubtedly  pathological  or  indicative 
of  a  diseased  condition,  it  does  not  follow  that  on  that  account  they 
are  stigmata  of  degeneracy.  As  has  already  been  shown,  there  are 
some  diseases  and  toxic  states  of  intra-  or  early  extra-uterine  life 
which  are  occasionally  capable  of  producing  secondary  amentia, 
and  in  these  cases,  although  the  germ  plasm  is  healthy,  there  may 
nevertheless  be  produced  physiological  and  anatomical  anomalies. 
There  are  also  other  diseases,  such  as  rickets  and  syphilis,  which 
may  not  produce  mental  deficiency,  and  yet  which  commonly  result 
in  bodily  abnormalities.  Even  in  cases  of  undoubted  degeneracy, 
such  as  primary  amentia,  some  of  the  body  conditions  which  are 
commonly  called  "  stigmata  "  seem  to  me  to  be  not  a  concomitant 
effect  of  the  germinal  imperfection,  but  the  result  of  the  imperfect 
nervous  action.  This  is  probably  the  case  with  such  physiological 
abnormalities  as  faulty  body  balance  and  carriage,  defective  co- 
ordination, and  even  peculiarities  of  physiognomical  expression. 
Lastly,  the  examination  of  perfectly  healthy  children  in  public 
elementary  schools,  as  well  as  of  ordinary  healthy  members  of  the 
general  population,  will  often  reveal  the  presence  of  so-called 
"  stigmata."  In  fact,  if  we  are  to  class  as  degenerates  all  persons 
coming  within  the  territory  defined  by  some  writers  on  this  subject, 
there  are  few  of  us  who  will  escape. 

I  am  far  from  denying  the  existence  of  degeneracy  and  its  stig- 
mata. '  In  fact,  I  consider  primary  amentia  itself  to  be  a  true 
degeneration,  and  many  of  the  anomalies  of  bodily  condition  present 
in  these  persons  may  rightly  be  described  as  "  stigmata  "  of  de- 
generacy. But  I  think  we  should  be  careful  to  restrict  this  term 
to  such  anomalies  as  are  really  manifestations  of  this  state — that  is, 
to  peculiarities  which  are  due  to  inherent  defects  of  the  germ  plasm. 
In  the  present  state  of  our  knowledge  this  differentiation  cannot 
always  be  made.  Some — indeed,  many — of  the  physical  charac- 
teristics of  amentia  to  be  described  are  certainly  the  result  of 
degeneracy,  and  it  is  not  surprising  that  such  should  be  numerous 
and  severe  in  this  condition,  in  the  lower  degrees  of  which  degeneracy 
reaches  its  culminating  manifestation.  But  some  of  these  charac- 
teristics are  not  really  degenerative,  and  therefore  I  think  it  better 
to  describe  them  all  simply  as  "  anomalies  "  until  such  time  as 
more  detailed  differentiation  is  possible. 

It  has  been  remarked  that  similar  anomalies  occur  in  persons  who 
are  not  otherwise  abnormal.     Nevertheless,  it  is  abundantly  clear 


Anomalies  of  Anatomical  Development      139 

that  they  are  far  more  numerous  in  neuropaths  and  in  aments  than 
in  the  general  population.  Further,  that  their  number  and  severity 
are,  on  the  whole,  directly  proportionate  to  the  degree  of  defect. 
Whilst,  therefore,  the  presence  of  a  single  anomaly  has  little  or  no 
diagnostic  importance,  the  presence  of  two,  three,  or  more  is  of 
considerable  significance  as  an  indication  of  mental  defect. 

The  table  in  the  Appendix  shows  the  various  anomalies  which 
have  been  noted  in  amentia;  the  chief  of  these  may  now  briefly 
Idc  described. 

Anomalies  of  Anatomical  Development. 

A.  Osseous  System. — Abnormal  conditions  of  the  skeleton  occur 
"with  extreme  frequency  in  amentia,  and  the  number  of  these  persons 
who  do  not  present  one  or  more  well-marked  bony  anomalies  is 
small.  The  cranium,  palate,  jaws,  and  teeth,  are  the  parts  most 
frequently  affected. 

Cranium. — Anomalies  of  the  cranial  vault  may  be  revealed  by 
inspection,  palpation,  and  mensuration;  also  by  tracings  from 
pliable  metal  bands  which  have  been  moulded  to  the  skull.  Pro- 
vided this  latter  method  is  carefully  performed,  it  yields  very 
accurate  results,  and  Dr.  Lapage*  has  recorded  a  most  interesting 
series  of  observations  taken  in  this  way.  The  process,  however,  is 
somewhat  too  tedious  for  general  work,  and  I  think  that  for  prac- 
tical purposes  mensuration  is  the  most  suitable.  The  following  are 
the  measurements  Thave  been  in  the  habit  of  taking  for  several  years ; 
they  have  the  advantage  of  being  easily  carried  out  and  recorded. 

The  measurements  are  taken  from  the  upper  point  of  attachment 
of  the  auricular  pinna  to  the  lateral  aspect  of  the  skull.  This  point 
was  suggested  to  me  many  years  ago  by  Dr.  J.  S.  Bolton  as  being 
readily  ascertainable  in  every  case,  and  subject  to  little  individual 
variation;  it  is  designated  "X."  From  the  fixed  point  "X"  of 
one  side  a  tape-measure  is  passed  in  various  directions  to  the  corre- 
sponding point  on  the  opposite  side — namely,  (a)  over  the  glabella, 
(b)  over  the  greatest  frontal  prominence,  (c)  vertically  upwards, 
(D)  over  the  greatest  parietal  prominence,  (e)  over  the  external 
occipital  protuberance.  An  additional  sagittal  measurement  is 
taken  from  the  glabella  over  the  cranial  vault  to  the  external  occipital 
protuberance,  and,  if  desired,  a  further  measurement  can  be  taken 
with  the  calipers  between  the  two  points  "  X." 

*  C.  P.  Lapage,  "  Feebie-mindedness  in  Children,"  Medical  Chronicle,  1905. 


140     The  Physical  Characteristics  of  Amentia 

These  measurements  are  conveniently  recorded  by  means  of  a 
diagram  like  the  following,  which  can  be  rapidly  drawn  as  occasion, 
requires,  or  printed  in  one  corner  of  the  case-sheet. 


It  will  be  observed  that  the  measurement  XAX  plus  XEX  gives  the  cranial, 
circumference,  XCX  its  vertical  perimeter,  and  XBX  and  XDX  the 
greatest  frontal  and  parietal  perimeters  respectively.  If  the  circumfer- 
ence be  multiphed  by  XBX  and  XDX,  a  figure  is  obtained  which  is  a 
convenient  index  of  the  total  cerebral  capacity. 

The  general  conclusion  at  which  I  have  arrived,  as  the  result  of 
an  extensive  series  of  measurements  of  the  crania  of  normal,  insane^ 
epileptic,  and  defective  persons,  is  that  in  the  majority  of  aments 
there  are  marked  departures  from  the  normal;  but  that  there  is  no- 
particular  type  of  skull  which  is  characteristic  of  that  condition. 
The  chief  anomalies  are  the  following :  Circumference :  The  average 
normal  circumference  of  the  male  adult  is  22  inches,  and  of  the 
female  2i|  inches.  The  circumference  at  other  ages  will  be  seen 
by  reference  to  the  Table  of  Developmental  Data.  Occasionally- 
the  skull  of  the  ament  exceeds  the  normal,  particularly  where- 
hydrocephalus  or  sclerosis  is  present ;  and  cases  presenting  cranial 
enlargement  are  sometimes  grouped  together  as  a  clinical  variety 
under  the  term  "  macrocephalics."  But  macrocephaly  may  arise- 
from  so  many  different  causes  that  I  think  this  is  to  be  deprecated. 
More  often  the  cranial  circumference  is  decidedly  less  than  the 
normal,  and  in  one  clinical  variety  of  amentia  (microcephaly)  it  is 
often  as  little  as  15  inches.  There  is  often  a  diminution  of  the 
frontal  and  parietal  perimeters,  whilst  a  subnormal  development  of 
the  occipital  portion  of  the  skull  is  exceedingly  common.  Sym- 
metry :  The  two  halves  of  the  normal  skull  not  infrequently  differ 
slightly  in  size,  but  this  condition  is  much  commoner  and  far  more 
marked  in  aments.  Where  paralysis  has  existed  from  an  early  age, 
this  condition  is  very  frequent,  the  lessened  measurement  corre- 
sponding to  the  area  of  brain  destroyed  or  arrested  in  its  develop- 
ment, but  asymmetry  of  the  cranium  is  often  observed  in  the 
absence'of  any  paralytic  signs.     Usually  the  left  half  is  the  smaller.. 


Anomalies  of  Anatomical  Development      141 

Lapage  found  that  lateral  asymmetry  occurred  in  158  cases  out  of  a 
total  of  198,  the  left  half  being  the  smaller  in  122,  and  the  right  in 
36.  Cranial  bosses  are  frequently  present,  probably  as  a  result  of 
rickets,  the  most  common  situations  being  the  ossific  centres  of  the 
frontal  and  parietal  bones.  In  a  few  cases  an  interfrontal  ridge  is 
seen.  Finally,  the  whole  conformation  of  the  skull  may  be  so 
unusual  as  to  merit  a  special  designation. 

The  following  are  the  three  chief  varieties :  Oxycephaly,  in  which 
there  is  such  a  marked  deficiency  in  the  frontal  and  occipital  regions 
that  the  skull  shelves  away  upwards  like  a  cone  or  "  sugar-loaf." 
This  is  a  characteristic  of  the  microcephalic  variety  of  aments. 
Scaphocephaly,  in  which  the  cranium  is  long  and  flattened  from  side 
to  side,  and  converges  upwards  to  a  central  "  keel"  situated  in  the 
sagittal  line,  thus  resembling  an  overturned  boat.  Spherical,  in 
which  the  whole  skull  is  small,  globular,  and  devoid  of  the  usual 
cranial  prominences;,  this  is  characteristic  of  Mongolism.  These 
various  anomalies  of  shape  and  symmetry,  as  well  as  the  total 
capacity,  can  be  roughly  but  readily  gauged  if  the  palm  and  out- 
stretched fingers  of  the  observer's  hand  are  placed  over  the  vertex 
of  the  skull. 

Palate. — The  association  of  abnormalities  of  the  palate  with 
mental  deficiency  has  long  been  recognized,  and  there  is  no  doubt 
that  it  is  one  of  the  commonest  malformations  occurring  in  this 
condition.  Many  years  ago  Langdon  Down*  drew  attention  to  the 
subject,  and  more  recently  Cloustonf  has  recorded  a  large  number 
of  observations  which  show  conclusively  that,  although  deformed 
palates  occur  in  the  normal,  they  are  far  and  away  more  frequent  in 
neuropaths  and  the  mentally  defective.  He  states  that  deformed 
palates  are  present  in  19  per  cent,  of  the  ordinary  population,  33  per 
cent,  of  the  insane,  55  per  cent,  of  criminals,  but  in  no  less  than 
61  per  cent,  of  idiots.  Petersen,|  who  has  made  a  most  exhaustive 
study  of  this  question,  and  has  compiled  an  elaborate  classification 
of  the  various  anomalies,  found  palatal  deformities  present  in  no 
less  than  82  per  cent,  of  aments,  in  76  per  cent,  of  epileptics,  and 
in  80  per  cent,  of  the  insane. 

Without  going  into  ultra-refinements,  it  may  be  stated  that  the 

*  J.  Langdon  Down,  Transactions  of  the  Odontological  Society  of  Great 
Britain,  1871. 

f  T.  S.  Clouston,  "  Neuroses  of  Development,"  1S91. 

X  Petersen  and  Church,  "  Nervous  and  Mental  Diseases,"  1904. 


142     The  Physical  Characteristics  of  Amentia 

majority  of  the  anomalies  met  with  may  be  arranged  under  two- 
headings  as  follows: 

1.  Saddle-  or  Keel-Shaped  Palates. — In  this,  the  commonest  type, 
there  is  a  contraction  of  the  alveolar  arch  between  the  bicuspid 
and  molar  teeth,  the  palate  at  the  same  time  extending  upwards 
to  a  considerable  distance,  at  the  expense  of  the  nasal  cavity.  In 
consequence  an  appearance  like  the  inside  of  a  saddle  or  boat's 
keel  is  produced.  It  is  sometimes  marked  by  a  narrow  central 
antero-posterior  furrow,  but  the  front  teeth  do  not  usually  pro- 
trude in  this  type  of  palate. 

2.  V-Shaped  Palates. — These  are  not  so  frequent  as  the  former, 
and  are  produced  by  a  gradual  narrowing  of  the  dental  arch  from 
the  first  molars  to  the  central  incisors,  the  point  of  the  V  being  thus 
directed  forwards.  Palates  of  this  type  may  also  be  higher  than 
normal,  and  the  narrowing  of  the  fore-part  of  the  arch  usually  causes 
considerable  overcrowding  and  protrusion  of  the  front  teeth. 

A  great  deal  of  discussion  has  raged  round  the  cause  and  manner 
of  production  of  these  anomalies.*  It  has  been  contended  by 
E.  S.  Talbot  that  they  only  appear  during  the  second  dentition, 
between  the  sixth  and  twelfth  years;  but  this  is  denied  by  Ciouston, 
John  Thomson,  and  other  physicians  of  great  experience,  and  I  have 
certainly  seen  numerous  instances  before  this  period.  I  think  there 
can  be  little  doubt  that  most  of  them  are  real  stigmata,  and  a  further 
indication  of  those  formative  defects  which  play  such  a  prominent 
part  in  the  production  of  amentia.  At  the  same  time  it  is  to  be 
remembered  that  the  palate,  like  the  external  ear,  is  probably 
undergoing  considerable  evolutionary  changes,  and  many  of  the 
slighter  anomalies  may  be  due  to  this  cause,  or  merely  be  an  ex- 
pression of  defective  nutrition  during  the  developmental  period. 

Cleft  palate  appears  to  be  on  quite  a  different  footing,  and  it  is 
doubtful  if  this  condition  and  its  common  associate,  hare-lip,  can 
be  regarded  as  real  stigmata  of  degeneracy.  It  is  but  rarely  met 
with  in  amentia,  Langdon  Down  finding  it  only  in  0-5  per  cent., 
and  Ireland  in  i  per  cent.,  of  idiots;  whilst  Talbotf  examined 
1,977  feeble-minded  children  without  meeting  a  single  instance. 
These  proportions  do  not  differ  materially  from  the  normal,  for 
Grenzer  (quoted  by  Talbot)  found  9  cases  on  examining  14,466  pre- 
sumably normal  children.     I  have  seen  many  instances  of  cleft 

*  See  the  chapter  on  "  Genetous  Idiocy  "  in  Ireland's  book. 
]  E.  S.  Talbot,  "  Degeneracy,"  1898. 


Anomalies  of  Anatomical  Development      143 

palate  and  hare-lip  in  children  who  presented  no  other  mental 
or  physical  imperfection  whatever. 

Jaws. — Many  aments  have  a  receding,  others  a  protruding, 
mandible,  the  former  being  very  common  in  microcephalics.  Asym- 
metry of  the  upper  or  lower  jaw  is  not  uncommon. 

Teeth. — Considering  the  frequent  occurrence  of  deformities  of 
the  palate,  it  is  not  surprising  to  find  that  anomalies  of  the  teeth 
are  very  common,  and  a  good  set  of  teeth  is  exceedingly  rare  in 
the  mentally  defective.  They  are  usually  late  to  appear,  mal- 
formed and  unhealthy  when  present,  and  prone  to  early  decay 
and  disappearance.  Where  a  V-shaped  palate  is  present,  the  upper 
incisors  and  canines  are  generally  huddled  together  and  protruding, 
at  times  to  such  an  extent  as  to  be  left  uncovered  by  the  lip.  The 
remaining  teeth  may  be  very  irregular  in  arrangement,  and  there 
are  often  large  gaps  between  them.  The  wisdom  teeth  are  seldom 
seen.  It  often  happens  that  the  teeth  erupt  at  different  planes  of 
the  alveolus,  and  I  have  occasionally  seen  a  complete  double  row 
of  incisors.  In  addition,  the  teeth  are  individually  ill-formed, 
often  honeycombed  or  marked  by  transverse  striae,  very  unhealthy, 
and  surrounded  by  a  foul  mass  of  exudation. 

Other  defects  of  the  osseous  system  are  seen  in  the  presence  of 
talipes,  polydactylism,  syndactylism,  and  various  deformities  of 
fingers  and  toes.  It  is  by  no  means  uncommon  to  find  two  fingers 
on  each  hand  welded  together,  and  occasionally  the  hand  con- 
sists of  thumb  and  an  ill-shaped  mass  composed  of  the  blending  of 
the  four  fingers — the  so-called  "  lobster  "  hand.  In  one  mentally 
deficient  child  presenting  this  last  anomaly  I  found,  on  inquiry,  that 
it  has  existed  in  the  antecedents  and  collaterals  for  three,  and 
possibly  four,  generations.  The  arms  are  often  disproportionately 
long. 

With  regard  to  stature,  a  condition  of  gigantism  may  be  present. 
This,  however,  is  exceptional,  and  as  a  rule  the  stature  is  dimin- 
ished, the  average  height  of  aments  being  several  inches  less  than 
that  of  the  ordinary  population.  This  was  shown  in  the  Final 
Report  of  the  Anthropometric  Committee  of  the  British  Associa- 
tion, issued  in  1882,  from  which  it  appears  that  of  all  the  various 
classes  of  the  community  investigated,  aments  are  both  the  smallest 
and  lightest  in  weight.  Dr.  H.  H.  Goddard,*  in  a  very  interesting 
paper  on  this  question,  finds  that  not  only  do  aments  as  a  class 

*  H.  H.  Goddard,  Journal  of  Nervous  and  Mental  Disease,  April,  191 2. 


144     ^^^  Physical  Characteristics  of  Amentia 

compare  very  iinfavourably  in  these  respects  with  the  normal 
population,  but  that  the  greater  the  degree  of  defect,  the  more 
marked  is  the  discrepancy.  In  the  case  of  the  feeble-minded,  he 
finds  that  whilst  growth  takes  place  in  a  practically  normal  manner 
during  the  earlier  years  of  life,  it  tends  to  be  arrested  at  a  lower 
age.  I  have  noticed  this  fact  myself,  but  only  in  the  case  of  the 
very  mildest  grade  of  defect,  and  of  aments  in  general  it  may  be 
said  that  growth  is  usually  defective  from  the  earliest  years  of  life. 

B.  Special  Sense  Organs — Ear. — It  is  probable  that,  owing  to 
alterations  which  have  taken,  and  are  taking  place  in  the  sense  of 
hearing,  the  external  ear  is  at  present  in  a  state  of  considerable 
evolutionary  instability.  It  is,  therefore,  not  surprising  to  find 
that  anomalies  of  this  structure  occur  in  normal  persons,  amongst 
whom,  as  a  matter  of  fact,  they  are  extremely  common.  This  being 
the  case,  it  is  evident  that,  as  an  indication  of  degeneracy,  such 
anomalies  are  in  themselves  of  little  value,  and  I  must  dissent  from 
the  dogmatic  utterances  of  some  writers  that  a  certain  type  of  ear 
can  be  labelled  "  criminal,"  another  "  insane,"  and  so  on.  At  the 
same  time,  there  is  no  doubt  that,  frequent  as  are  such  departures 
from  the  normal  in  the  ordinary  population,  they  are  stiU  very 
much  more  frequent  in  degenerates;  and  when  they  occur  in  com- 
bination with  two  other  classes  of  defects — namely,  of  the  cranium 
and  palate — I  believe  that  they  have  considerable  diagnostic  value. 

With  regard  to  the  frequency  of  auricular  defects,  the  figures 
ascertained  by  Gradenigo,*  although  they  do  not  relate  specifically 
to  amentia,  are  of  considerable  interest.  As  the  result  of  his 
examination  of  several  thousands  of  persons  of  both  sexes,  this 
observer  foimd  that  the  external  ears  were  regular  and  normal — 
in  56  per  cent,  of  males  and  66  per  cent,  of  females  of  the  ordinary 
population;  in  36  per  cent,  of  males  and  46  per  cent,  of  females  of 
the  insane  population ;  and  in  28  per  cent,  of  males  and  54  per  cent, 
of  females  of  the  criminal  population.  Also  that  in  the  insane  and 
criminal  classes,  not  only  were  ear  anomalies  more  frequent,  but 
they  were  of  greater  gravity.  As  tending  to  show  that  some  ear 
anomalies  may  be  progressive  rather  than  retrogressive,  it  may  be 
stated  that  Talbot  found  certain  varieties  were  more  frequent  in 
ordinary  persons  than  in  degenerates. 

The  varieties  of  malformation  of  this  structure  which  are  met 

*  Gradenigo  {Arch,  de  Psychiatria,  1890  and  1892),  quoted  by  Talbot  in 
"  Degeneracy." 


Anomalies  of  Anatomical   Development      145 

with  in  persons  suffering  from  amentia  are  so  numerous  that  a 
detailed  account  of  them  all  is  impossible.  There  is  no  portion  of 
the  external  ear  which  may  not  be  affected,  but  the  following  are 
the  chief  conditions  met  with:  Defects  of  the  lobule  are  decidedly 
the  most  frequent;  it  is  often  unusually  large  and  fleshy;  it  may, 
however,  be  smaller  than  usual,  and  at  times  even  absent;  it  is 
occasionally  adherent  to  the  face.  Another  very  common  deformity 
is  that  in  which  the  whole  ear  is  excessively  large,  prominent,  and 
outstanding,  with  a  marked  convexity  as  seen  from  behind. 
Another  common  t}^e  is  the  reverse  of  this,  the  entire  pinna  being 
small,  thin,  and  circular,  strongly  recalling  the  ear  of  the  chim- 
panzee. With  or  without  any  of  these  gross  changes  there  may  be 
numerous  minor  malformations  of  the  helix  and  antihelix,  the 
tragus  and  antitragus.  Supernumerary  auricles  are  occasionally 
present,  but  I  do  not  think  that  anomalies  of  the  Darwinian  tubercle 
are  more  frequent  in  aments  than  in  the  normal  population.  It 
is  very  common  to  find  the  ears  markedly  different  on  the  two 
sides.  It  occasionally  happens  that  the  auditory  apparatus  is  so 
imperfectly  developed  that  total  or  severe  deafness  results.  This, 
however,  is  uncommon,  and  deafness,  when  present,  is  usually  the 
result  of  disease,  especially  suppuration  of  the  middle  ear. 

Eye. — Anomalies  of  the  eye  and  its  appendages  are  exceedingly 
-common  in  aments,  those  most  frequently  seen  being  the  following. 
Epicanthus,  a  ridge  of  skin  continued  from  the  upper  eyelid  around 
the  inner  canthusj  it  is  apparently  due  to  an  unusual  redundancy 
of  skin  in  this  region,  and  disappears  whilst  the  skin  over  the  bridge 
of  the  nose  is  pinched  up  between  the  fingers;  it  may  be  unilateral, 
but  usually  affects  both  eyes,  and  is  a  tolerably  frequent  anomaly 
in  aments,  although  not  unknown  in  normal  children.  Palpebral 
fissures  which  are  small  and  obliquely  placed,  so  that  the  inner  is 
lower  than  the  outer  end,  are  a  characteristic  feature  of,  and  give 
the  name  to,  the  Mongolian  variety  of  amentia.  Differently 
coloured  and  speckled  irides  are  very  common,  as  also  are  strabis- 
mus, astigmatism,  hypermetropia,  and  less  frequently  myopia  and 
nystagmus.  Corneal  opacities  are  frequent,  and  a  small  proportion 
of  the  lower  grades  are  congenitally  blind ;  but  colour-blindness  does 
not  appear  to  be  more  prevalent  than  in  the  ordinary  population. 

Nose. — A  clear-cut,  well-formed  nose  is  not  often  seen  in  aments, 
and  this  organ  is  usually  either  considerably  flattened  or  de- 
pressed, or  is  large  and  prominent,  with  wide  fleshy  nostrils  which 


146     The  Physical  Characteristics  of  Amentia 

look  forwards  rather  than  downwards.  Deviation  of  the  septum 
and  nasal  bones  may  also  occur. 

The  Lips  are  often  thick,  coarse,  prominent,  and  unequal  in  size. 
The  mouth  is  heavy  and  flabby- looking,  generally  open,  and  devoid 
of  either  refinement  or  firmness.     Hare-Hp  is  not  common. 

The  Tongue  is  often  abnormally  large,  fissured,  and  its  papillae 
hypertrophied,  particularly  in  the  Mongolian  variety. 

C.  Muscular  and  Cutaneous  Systems. — Various  anomalies  of  the 
skeletal  muscles  have  been  found  upon  dissection,  but  they  are 
hardly  of  sufiicient  importance  to  merit  further  description.  Ab- 
normahties  of  the  skin  are  frequent,  and  consist  of  coarseness  of 
the  integument,  excessive  and  unpleasant  secretion,  webbing  of  the 
fingers,  moles,  and  nsvi.  There  is  often  an  excessive  development 
of  hair  upon  parts  usually  hairless,  and  a  lack  or  deficiency  upon 
those  which  are  generally  covered,  particularly  the  face  and  chin 
in  males.  The  finger-  and  toe-nails  are  often  very  imperfectly 
formed. 

Adenoma  Sebaceum. — In  this  place  reference  may  be  made  to 
this  peculiar  condition  of  the  skin  sometimes  seen  in  aments,  and 
with  extreme  rarity  in  normal  individuals.  Indeed,  with  the  excep- 
tion of  two  patients,  all  the  cases  seen  by  Crocker  have  been  in 
imbeciles  or  chronic  epileptics.  Adenoma  sebaceum  is  a  papular 
new  growth  which  is  confined  to  the  face,  and  is  chiefly  seen  on  the 
side  of  the  nose,  but  occasionally  on  the  forehead  or  chin.  It  is 
usually,  but  not  always,  symmetrical,  and  the  lesions  are  often 
numerous.  They  are  either  firmly  embedded  in,  or  project  from, 
the  skin,  and  they  vary  in  size  from  a  pin-head  to  a  small  pea.  They 
are  of  a  whitish  or  yellowish  colour,  but  sometimes  bright  red 
owing  to  numerous  telangiectases.  The  papules  are  made  up  of  an 
overgrowth  of  sebaceous  glands  and  capillary  vessels,  often  sur- 
mounted by  a  thickened  corium.  In  many  cases  they  are  present 
at  birth,  but  in  others  they  do  not  appear  until  late  in  childhood 
or  puberty.  As  a  rule  they  persist  throughout  life,  but  occasionally 
undergo  spontaneous  involution  with  scarring.* 

D.  Circulatory  and  Respiratory  Systems. — The  most  important 
anomalies  are  stenosis  of  the  pulmonary  arterj^  and  defects  of  the 
auricular  and  ventricular  septa.  The  heart  is  usually  smaller  than 
that  of  a  normal  person  of  corresponding  weight. 

*  See  Pringle,  British  Journal  of  Dermatology,  1890,  vol.  ii.,  and  Crocker,. 
"  Diseases  of  the  Skin,"  1893. 


Anomalies  of  Physiological  Function        147 

E.  Alimentary  Systems. — Numerous  anomalies  of  the  various 
organs  of  this  system  have  been  observed  upon  dissection.  Meckel's 
diverticulum  is  not  very  rare,  and  Talbot  states  that  the  appendix 
is  best  developed  in  degenerates. 

F.  Urinary  and  Generative  Systems. — Lobulation  of  the  kidneys 
is  not  uncommon,  and  anomalies  of  the  genital  organs  are  of  con- 
siderable frequency.  These  consist,  in  the  male,  of  epi-  and  hypo- 
spadias, infantile  condition  of  the  penis,  and  cryptorchism ;  in 
the  female  an  infantile  condition  of  the  uterus  is  generally 
present,  and  the  ovaries  are  often  fibrous.  Cloacal  openings 
have  been  observed  in  both  sexes.  Supernumerary  mammae  are 
common. 

G.  Nervous  System. — These  anomalies  have  already  been  de- 
scribed in  the  chapter  dealing  with  Pathology. 


Anomalies  of  Physiological  Function. 

It  is  naturally  to  be  expected  that  organs  which  are  the  site  of 
grave  defects  of  structure  or  anomalies  of  anatomical  development 
should  also  be  imperfect  in  their  working,  and  hence  physiological 
anomalies  are  exceedingly  frequent  in  the  mentally  defective. 
Thus,  the  condition  of  the  heart  leads  to  an  enfeebled  circulation, 
so  that  cyanosis  and  coldness  of  the  extremities,  chilblains,  and 
sores  are  exceedingly  common.  Defects  of  the  organs  of  special 
sense  are  a  factor  in  producing  a  diminished  perceptivity.  Non- 
development  of  cortical  areas  or  of  the  internal  structures  of  the 
encephalon  cause  various  degrees  of  paralysis,  with  their  accom- 
panying deformities.  Indeed,  the  mental  deficiency  itself  may  be 
considered  as  an  imperfection  of  physiological  function  due  to 
neuronic  changes,  whilst  the  various  neuroses  and  psychoses,  such 
as  insanity,  epilepsy,  hysteria,  and  one-sided  genius,  as  well  as  the 
moral  perversions,  seen  in  prostitution,  inebriety,  and  other  anti- 
social and  criminal  tendencies,  are  of  the  same  order. 

With  regard  to  the  functions  of  the  generative  organs,  there  is  no 
doubt  that  many  of  these  persons  can  propagate  their  kind,  and 
there  are,  unfortunately,  numerous  examples  where  this  has  taken 
place.  The  milder  aments,  indeed,  appear  to  be  unusually  prolific. 
At  the  same  time,  in  the  male  sex,  the  advent  of  puberty  is  often 
considerably  delayed,  and  may  not  appear  until  late  in  the  teens. 
In  the  male  this  subject  has  been  very  fully  investigated  by  Bourne- 


148     The  Physical  Characteristics  of  Amentia 

ville  and  Sollier,*  who  drew  attention  to  a  considerable  retardation, 
of  puberty,  as  well  as  to  the  presence  of  frequent  genital  anomalies 
like  those  referred  to.  In  the  female,  on  the  other  hand,  a  similar 
retardation  does  not  appear  to  be  the  case,  and  it  is  stated  by  Jules 
Voisin,t  who  has  studied  the  subject  closely,  that  the  development 
of  puberty  takes  place  at  a  normal  age,  and  that  menstruation  recurs 
at  regular  periods.  Doubtless  of  many,  or  even  most,  female  aments 
this  is  true,  and  amenorrhoea  and  dysmenorrhoea  do  not  appear  to  be 
commoner  in  them  than  in  those  of  normal  intelligence ;  indeed,  the 
latter  seems  to  be  less  so.  It  is,  however,  to  be  remembered  that 
in  some  of  the  pronounced  idiots  menstruation  never  appears  at  all. 

Rene  and  Henri  Larger  have  drawn  attention  to  the  obstetrical 
stigmata  of  degeneracy;  indeed,  they  have  formulated  a  law  that, 
"  given  any  anomaly  of  gestation,  one  can  always  and  necessarily 
conclude  the  presence  of  hereditary  antecedents,  either  neuro- 
pathic, or  psychical,  or  teratologic al,  of  either  of  the  generators, 
or  both."  Their  conclusions  have  been  stoutly  contested  by  Porak, 
and  defended  with  equal  vigour  by  Roy.  Whilst  not  being  pre- 
pared to  go  so  far  as  MM.  Larger,  I  think  it  is  certainly  a  fact  that 
anomalies  of  gestation  and  parturition  are  much  commoner  in  the 
degenerate  than  in  the  normal  population. 

It  may  be  remarked  that  the  majority  of  mentally  defective 
children  are  late  in  'acquiring  control  over  the  bladder  and  rectum ; 
indeed,  in  the  lowest  grades  such  control  may  never  be  developed. 

A  similar  retardation  of  physiological  action  is  seen  with  regard 
to  dentition,  speech,  and  walking.  Inquiries  show  that  a  large 
proportion  of  aments  do  not  cut  their  first  or  second  teeth  until 
some  considerable  time  after  the  ordinary  period.  Many  of  them 
do  not  attempt  to  stand  until  their  third  year,  and  walking  is  corre- 
spondingly late.  In  many  cases  the  child  is  four  or  five  years  old 
before  it  says  a  word. 

But  in  addition  to  these  functional  defects  of  particular  organs, 
many  aments  are  characterized  by  a  physiological  inadequacy  which 
is  general  and  widespread.  Their  temperature-regulating  mechan- 
ism is  so  imperfect  that  colds  and  chills  are  exceeding  common. 
Their  metabolism  is  so  defective  that,  in  spite  of  abundance  of 
wholesome  food,  most  of  them  remain  small,   stunted,   and  ill- 

*   Bourneville  and  Sollier,    "  Anomalies   des   Organes   Genitaux   chez   les 
Idiots  et  les  Imbeciles,"  Progrds  Medical,  1888. 
t   Jules  Voisin,  "L'Idiotie,"  1893. 


Mortality  1 49 

nourished.  It  is  probably  the  same  defect  which  causes  so  many- 
female  aments  to  become  excessively  fat  and  ungainly  after  the 
climacteric.  They  have  an  increased  predisposition  to  illness,  and 
readily  contract  disease,  and  their  physiological  margin  and  power 
of  resistance  are  so  diminished  that  disease  quickly  pr.oves  fatal. 
In  fact,  the  history  of  a  very  large  proportion  of  these  patients  may 
be  expressed  in  two  words — defective  vitality — and  the  supervision  of 
the  physician  is  often  as  necessary  for  their  bodily  as  for  their  mental 
ailments.  The  late  Dr.  Langdon  Down  remarked  the  fact  that 
"  many  cases  of  imbecility,  particularly  those  of  the  Mongolian 
variety,  lose  a  large  amount  of  intellectual  energy  in  the  winter — 
go  through,  in  fact,  a  process  of  hybernation,  their  mental  power 
being  always  directly  as  the  external  temperature." 


Mortality. 

The  physical  welfare  of  the  ament  of  to-day  is  the  subject  of  far 
more  care  and  attention  than  was  the  case  a  few  generations  back. 
Then  many  perished  who,  under  present  conditions,  would  have 
survived ;  and  there  can  be  no  doubt  that  modern  medical  and  sur- 
gical practice,  together  with  advances  in  preventive  medicine,  have 
diminished  the  mortality  rate,  not  only  of  the  fit,  but  of  the  unfit  also. 

Nevertheless,  the  vitality  of  aments  as  a  class  is  decidedly  inferior 
to,  and  their  expectation  of  life  still  remains  appreciably  less  than, 
that  of  the  ordinary  population.  Even  amid  the  well-ordered  sur- 
roundings of  an  institution  the  number  of  these  persons  of  at  all 
advanced  age  is  relatively  small,  and  in  the  world  outside  the  pro- 
portion is  still  less.  I  am  disposed  to  think  that  the  mortality  has, 
generally  speaking,  a  direct  relation  to  the  degree  of  deficiency.        ! 

This  diminished  expectation  of  life  was  well  shown  by  some 
figures  collected  by  Dr.  Shuttleworth  with  regard  to  patients  in  the 
Royal  Albert  and  Earlswood  Asylums.  Dr.  Shuttleworth  found 
that  at  all  the  quinquennial  periods  from  the  fifth  to  the  twentieth 
year  of  life  the  mortality  rate  of  aments  was  between  nine  and  ten 
times  as  great  as  it  was  amongst  the  general  population.  This 
higher  mortality  rate  at  the  earlier  ages  of  life  is  shown  by  some 
recent  figures  supplied  by  the  Lunacy  Commissioners,  in  which  the 
mortality  rate,  at  different  age  periods,  of  the  inmates  of  idiot 
institutions  (which  include  all  grades  of  amentia)  is  contrasted  with 
similar  rates  for  the  whole  population. 


150     The  Physical  Characteristics  of  Amentia 


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Mortality 


151 


The  same  liability  to  early  death  is  also  shown  by  the  following 
table,  which  gives  the  ages  at  death  of  1,000  consecutive  deaths  in 
Earlswood  Training  Institution.  For  these  particulars  I  am  greatly 
indebted  to  Dr.  C.  Caldecott,  Medical  Superintendent,  and  Dr. 
F.  H.  Pearce,  Assistant  Medical  Officer. 


TABLE  X. 

Showing  Age  Periods  of  1,000  Consecutive  Deaths  in  Earlswood 
Asylum,  dating  back  from  October,  1907.* 


Males. 

Females. 

Under  5  years  .  . 

2 

I 

5  to  9   , 

70 

40 

10  „  14 

162 

71' 

15  ..  19   , 

180 

lOI 

20  ,,  24   , 

88 

42 

25  ,.   34   , 

66 

38 

35  .,  44   , 

37 

28 

45  ..  54   . 

22 

12 

55  ,.   64   , 

20 

9 

65  ..  74   . 

6 

4 

75  ..   84   . 

— 

I 

Total 

. 

653 

347 

I, coo 

Owing  to  the  impracticability  of  ascertaining  the  total  number  of 
persons  alive  at  corresponding  ages,  these  figures  cannot,  of  course, 
be  compared  with  the  mortality  tables  relating  to  the  general  popu- 
lation. They  are,  nevertheless,  of  considerable  interest  as  further 
corroboration  of  the  fact  shown  in  Table  IX. — namely,  that  the 
highest  death-rate  falls  between  the  fifteenth  and  twentieth  years, 
the  period  of  life  in  which  the  mortality  rate  is  lowest  among  the 
general  population. 

The  following  table,  also  kindly  supplied  by  Dr.  Caldecott,  is  of 
interest  as  showing  the  percentage  of  deaths  to  the  ntmiber  of 
patients  in  residence  at  Earlswood  Asylum  over  a  period  of  twenty- 
one  years.  It  is  impossible  by  means  of  these  figures  to  institute 
an  accurate  comparison  between  the  mortality  of  aments  and  of  the 

*  Patients  under  the  age  of  six  are  not  eligible  for  the  institution,  excepting 
those  that  come  in  on  payment  scales. 


152     The  Physical  Characteristics  of  Amentia 

general  population,  for  the  reason  already  mentioned;  neverthe- 
less, they  afford  clear  evidence  of  the  excessive  mortality  rate  in 
aments.  The  crude  annual  death-rate  in  England  and  Wales  per 
1,000  persons  living,  of  all  ages  and  both  sexes,  is  well  under  20, 
whereas  we  see  that  even  in  a  well-equipped  and  excellently 
managed  institution  like  Earlswood  the  average  mortality  is  over 


TABLE  XL 

Showing  the  Percentage  of  Deaths  to  the  Number  of  Patients  in 
Residence  at  Earlswood  Asylum  over  a  Period  of  Twenty-One 
Years,  from  December  31,  1890,  to  December  31,  1910. 


Percentage  of  Deaths 

to  Average. 

Year. 

Number  Resident. 

Males. 

Females. 

Total. 

/iSgo             

I -91 

3.66 

2'46 

1891 

1-58     j     4-68 

2-56 

1892 

3-05 

3.22 

3-IO 

1893 

4-55 

4-i8 

4-42 

1894 

3-63 

6-88 

4-37 

M 

1895 

2*04 

3-24 

2-40 

fr> 

1896 

3-09 

4-25 

3-40 

^ 

1-897 

2-88 

3.66 

3-14 

rO 

1898 

3-50 

3-72 

3-61 

1899 

2-73 

3.80 

3-II 

l< 

1900 

3-17 

2-l8 

2-83 

Q 

1901 

2*40 

3-93 

2-93 

to 

1902 

1.78 

3-91 

2-52 

'3 

1903 

2-65 

6-89 

4.09 

a 

1904 

6'00 

5-8o 

5-99 

1905 

3-50 

4'20 

3-70 

1906 

2-25 

7-04 

3-75 

1907 

3-19 

5-94 

4'02 

1908 

4-23 

2M9 

3.60 

1909 

3-24 

3-70 

3-38 

V1910 

■ 

2*71 

5-i8 

3-43 

30  per  1,000,  and  this  relates  to  a  selected  age  class,  there  being  a 
disproportionately  small  number  of  persons  over  middle  age  and 
practically  none  under  six  years,  so  that  the  two  most  vulnerable 
life  periods  are  excluded. 


Causes  of  Death 


153 


Causes  of  Death. 

The  causes  of  death  in  1,000  consecutive  deaths  are  shown  in 
Table  XIII.  (pp.  154,  155).  The  figures  there  given  must  not,  of 
course,  be  confounded  with  the  ordinary  mortahty  rates  from  the 
various  diseases;  nevertheless  they  are  of  considerable  value  as 
showing  the  relative  incidence  of  the  various  fatal  diseases  in 
aments. 

It  is  seen  from  this  table  that  by  far  the  commonest  cause  of 
death  is  tuberculosis,  which  accounts  for  39'6  per  cent.,  or  nearly 
two-fifths,  of  those  dying.  The  fatal  varieties  of  this  disease  are 
as  follows: 


TABLE  XH. 

Males. 

Females. 

Total. 

Pulmonary  tuberculosis 
General                    ,, 
Meningeal 
Abdominal              ,, 
Osseous                    ,, 

.  .     j 

199 
37 
10 

9 
6 

106 

17 
I 
8 
3 

305 
54 
II 

17 
9 

261 

135 

396 

The  next  most  common  cause  of  death  is  epileptic  convulsions, 
which  claims  ij'j  per  cent,  of  the  total;  whilst  pneumonia  is  a  very 
good  third,  being  responsible  for  10-4  per  cent,  of  total  deaths.  It 
is  interesting  to  note  that,  excluding  tubercle,  the  nervous  system 
is  the  part  most  frequently  involved  by  fatal  disease,  being  fol- 
lowed in  order  by  the  respiratory,  circulatory,  alimentary,  and 
urinary  systems.  Not  that  diseases  of  the  nervous  system  are  the 
cause  of  the  mental  deficiency,  but  because  the  imperfection  of 
development  and  imperfect  function  of  the  nervous  system  render 
it  peculiarly  prone  to  disease. 


154     The  Physical  Characteristics  of  Amentia 


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CHAPTER  VIII 

FEEBLE-MINDEDNESS    IN    CHILDREN 
(MENTALLY  DEFECTIVE  CHILDREN) 

The  term  feeble-mindedness  is  applied  to  the  mildest  of  the  three 
degrees  of  amentia.  In  the  grade  of  their  deficiency  there  is  no 
difference  between  the  feeble-minded  child  and  adult;  but  as  the 
former  are  subject  to  the  provisions  of  a  special  Act  of  Parliament, 
which  brings  them  within  the  jurisdiction  of  the  education  authority, . 
it  is  necessary  to  consider  them  separately.  In  this  chapter,  there- 
fore, we  shall  consider  feeble-minded  persons  below  the  age  of 
sixteen  years,  or,  as  they  are  designated  in  the  Act,  mentally  defec- 
tive children ;  those  over  this  age  will  be  described  as  "  feeble- 
minded adults  "  subsequently. 

After  the  passing  of  the  Education  Act  of  1876,  making  attend- 
ance at  public  elementary  or  other  schools  compulsory,  it  gradually 
became  apparent  that  a  group  of  children  existed  who  were  so  far 
mentally  defective  that  they  could  not  be  satisfactorily  taught  in 
the  ordinary  public  schools,  but  who  were  not  sufficiently  defective 
to  be  certified  as  imbeciles  or  idiots  under  the  Idiots  Act  of  1886. 
Many  particulars  regarding  this  class  were  brought  to  light  through 
the  inquiries  of  medical  men  and  scientific  and  philanthropic 
societies,  amongst  whom  special  mention  must  be  made  of  Dr. 
Francis  Warner,  Dr.  Fletcher  Beach,  Dr.  Hack  Tuke,  and  Dr. 
Shuttleworth ;  the  British  Association,  the  British  Medical  Asso- 
ciation, and  the  Charity  Organization  Society.  The  researches  of 
Dr.  Francis  Warner  in  particular  were  of  the  most  painstaking 
nature,  and  were  based  upon  the  examination  of  100,000  school- 
children.*    As  a  result  of  these  inquiries,  a  Departmental  Com- 

*  See  "  Report  on  the  Scientific  Study  of  the  Mental  and  Physical  Con- 
ditions of  Childhood,"  Parkes  Museum,  1895;  also  "Report  on  the  Feeble- 
minded," etc.,  C.O.S.,  1892. 

156 


Feeble-Mindedness  in   Children  i  z^j 

mittee  of  the  Board  of  Education  was  appointed  in  1896  to  con- 
sider and  report  upon  the  question. 

This  Committee  presented  its  report  in  1898.*  It  recognized 
that  a  number  of  children  existed  in  public  elementary  schools  who, 
in  their  mental  capacity,  were  intermediate  between  the  ordinary 
"  dullards  "  and  certifiable  imbeciles,  and  it  estimated  the  propor- 
tion of  this  class  as  approximately  i  per  cent,  of  the  elementary 
school  population.  Its  inquiries  showed  that  these  children  were 
incapable  of  receiving  proper  benefit  from  the  ordinary  instruction 
in  these  schools,  but  that  they  were  capable  of  receiving  consider- 
able benefit  from  the  individual  attention  and  instruction  given  in 
special  classes — that,  in  fact,  under  such  conditions  there  was  a 
fair  prospect  of  many  of  them  being  enabled  to  take  their  place  in 
the  world.  It  considered  that  these  defective  children  would  suffer 
by  association  with  imbeciles,  and  should  not,  therefore,  be  educated 
with  them;  and  it  recommended  that  special  classes  and  schools 
should  be  established  to  meet  their  requirements.  This  report  led 
to  the  passing  in  the  following  year  of  the  Defective  and  Epileptic 
Children  (Education)  Act. 

This  Act  (62  and  63  Vict.,  ch.  32,  1899)  was  the  first  legal  recog- 
nition in  this  country  of  the  mildest  or  feeble-minded  grade  of 
amentia.  It  defines  the  class  as  those  children  who,  "  not  being 
imbecile,  and  not  being  merely  dull  and  backward,  are  defective — that 
is  to  say,  by  reason  of  mental  {or  physical)  defect  are  incapable  of 
receiving  proper  benefit  from  the  instruction  in  the  ordinary  public 
elementary  schools,  but  are  not  incapable  by  reason  of  such  defect  of 
receiving  benefit  from  instruction  in  such  special  classes  and  schools 
as  are  in  this  Act  mentioned." 

This  Act,  therefore,  clearly  differentiates  between  the  mildest 
degree  of  mental  defect  and  the  more  pronounced  affection  of  im- 
becility, and  although  it  does  not  apply  the  term  "  feeble-minded  " 
to  this  class,  the  condition  it  defines  is  practically  identical  with  that 
to  which  this  term  has  for  long  been  specifically  applied  in  this 
country.  It  is  probable  that  in  some  of  these  children  the  mental 
defect,  although  permanent,  is  not  sufficiently  severe  to  justify 
their  inclusion  within  the  category  of  amentia  as  defined  in  this 
book.  But  such  cases  are  exceptional,  and  in  my  experience  the 
great  bulk  of  the  children  who  come  within  the  definition  just 

*  "  Report  of  the  Departmental  Committee  on  Defective  and  Epileptic 
Children,"  1898. 


158  Feeble-Mindedness  in  Children 

quoted  are,  in  later  life,  incapable  of  maintaining  existence  with- 
out supervision,  and  are  therefore  true  aments;  they  are,  in  fact 
the  juvenile  feeble-minded.  This  is  recognized  by  the  Mental 
Deficiency  Act  of  1913,  which  defines  feeble-minded  children  as 
those  who,  "  by  reason  of  mental  defectiveness  (from  birth  or  from 
an  early  age,  not  amounting  to  imbecility),  appear  to  be  per- 
manently incapable  of  receiving  proper  benefit  from  the  instruction 
in  ordinary  schools."  The  Education  Act  permits  the  local  educa- 
tion authorities  to  establish  special  classes  and  schools  for  the 
mental  defectives  within  their  district,  and  where  such  are  estab- 
lished attendance  is  compulsory  up  to  the  age  of  sixteen  years, 
.instead  of  fourteen,  as  in  the  ordinary  schools.  Unfortunately, 
owing  to  its  permissive  and  not  obligatory  nature,  the  Act  still 
remains  a  dead  letter  in  many  parts  of  the  country ;  but  since  it  has 
been  adopted  by  the  whole  of  London,  as  well  as  by  over  twenty 
of  the  largest  towns  of  England,  the  education  of  mentally  defective 
children  may  now  be  said  to  have  become  an  integral  and  important 
part  of  the  educational  system  of  the  nation,  and  there  is  every 
reason  to  think  that  this  Act  will  shortly  be  made  compulsory. 

The  investigations  instituted  by  the  Royal  Commission  of  1904 
yielded  much  further  light  upon  the  number  and  condition  of  this 
class ;  but  whilst  agreeing  in  several  respects  with  the  conclusions 
previously  arrived  at,  they  differed  on  two  important  points. 
Firstly,"  as  will  be  seen  immediately,  the  i  per  cent,  estimate  was 
found  to  be  somewhat  too  high;  secondly,  a  more  extended  ex- 
perience of  these  children  showed  that  the  views  which  were  formerly 
held  as  to  the  amount  of  amelioration  under  training,  and  their 
possibility  of  becoming  self-supporting  citizens,  were  too  optimistic. 

Numerical  Incidence. 

Owing  partly  to  the  difficulty  attending  diagnosis,  and  partly  to 
the  great  variations  of  incidence  in  different  localities,  the  precise 
enumeration  of  mentally  defective  children  is  practically  impossible, 
and  all  that  can  be  given  is  an  approximate  estimate.  From  the 
statistics  furnished  by  the  investigators  appointed  by  the  Royal 
Commission  it  may  be  calculated  that,  on  the  average,  073  per 
cent,  of  the  children  attending  the  public  elementary  schools  of 
England  and  Wales  belong  to  this  class.  There  are,  however,  another 
o-io  per  cent,  who,  for  various  reasons,  are  not  attending  elementary 


Numerical  Incidence 


159 


schools,  and  if  these  be  added,  the  proportion  of  mental  defectives  is 
raised  to  0-83  per  cent,  of  the  school  population,  corresponding  to  a 
total  of  50,665  mentally  defective  children  of  school  age  in  England 
and  Wales  in  the  year  1905.  The  returns  which  have  since  been 
furnished  to  the  Board  of  Education  by  school  medical  officers 
throughout  the  country  would  indicate  that  the  proportion  of 
defective  children  in  the  school  population  is  somewhat  less  than 
this — namely,  about  0-5  per  cent.;  but  as  routine  of&cial  inquiries 
can  rarely  be  as  exhaustive  as  special  investigations,  I  am  disposed 
to  think  that  the  figures  of  the  Royal  Commission  more  nearly 
represent  the  true  incidence. 

But,  as  will  be  seen  from  the  accompanying  Table  XIV.,  showing 
the  percentages  in  the  respective  districts  investigated,  this  figure  is 
the  mean  average  of  two  widely  divergent  extremes.  In  Durham, 
for  instance,  the  percentage  is  only  0-24,  whilst  in  Dublin  it  is  as 
high  as  1-85,  and  it  becomes  necessary  to  consider  the  cause  of  these 
extreme  variations. 


TABLE  XIV. 

Showing  the  Percentage  of  Mentally  Defective  Children  to  the 
Public  Elementary  School  Population  in  Certain  Districts 
investigated  by  the  Royal  Commission  of  1904. 


District. 

Percentc 

Urban    . .          ; .  - 

'  Manchester 
Birmingham 

Hull             

Glasgow 

DubUn        

Belfast        

I'20 

••      1-03 

0-30 

•  •      0-74 

..      1-85 

0*50 

[  Stoke-on-Trent 
Industrial          . .  4  Dtirham 

[Cork            

• .      0-59 

0-24 

••      0-35 

Mixed  industrial  /Nottinghamshire  , . 
and  agricultural  ( Carmarthenshire  . . 

. .      0-66 
0-76 

Agricultural      . .  ^ 

'Somersetshire 
Wiltshire    .  . 
Lincolnshire 
Carnarvonshire 
.Galway 

.  .      0'6i 

•  •      0-55 

0-96 

•  •      0-47 
••      1-33 

Much  of  the  difference  is  clearly  related  to  the  fact  that  the 
incidence  of  mental  abnormality  in  general  (insanity  and  amentia) 
is  not  uniform  throughout  the  country,  but  is  subject  to  very  con- 
siderable variation  from  causes  which  at  present  are  not  fully 


i6o  Feeble -Mindedness  in   Children 

understood.  This  we  shall  not  consider.  But  there  are  smaller 
variations  which  appear  to  be  dependent  upon  sociological  and 
other  influences,  and  since  these  relate,  not  to  mental  abnormality 
in  general,  but  to  the  particular  class  with  which  we  are  now  deahng, 
they  must  be  referred  to. 

Relative  Incidence  in  Town  and  Country. — It  has  been  shown 
that  although  amentia  as  a  whole  is  more  prevalent  in  rural,  and 
insanity  in  urban,  districts,  and  the  number  of  idiots  and  imbeciles 
in  the  country  far  exceeds  that  in  the  towns,  nevertheless  the  in- 
cidence of  mentally  defective  children  is  decidedly  greater  in  the 
towns  than  in  the  country.  In  view  of  the  fact  that  these  children 
differ  only  in  degree,  and  not  in  kind,  from  the  idiots  and  imbeciles, 
this  is  in  itself  singular;  but  it  becomes  even  more  so  when  it  is 
found  that  the  feeble-minded  adult,  who  is  simply  the  mentally 
defective  child  grown  up,  is  not  more  prevalent  in  town  than  in 
country,  but  is  actually  less  so.  What,  then,  is  the  cause  of  this 
excess  of  mentally  defective  children  in  a  town  as  compared  with 
a  country  environment  ? 

The  answer  which  at  once  suggests  itself  is  that  the  many  adverse 
factors  of  the  environment  of  our  towns,  the  improper  feeding, 
the  faulty  ventilation,  the  overcrowding,  and,  in  fact,  slum  life 
generally,  are  responsible  for  the  excess;  and  since  a  history  of 
morbid  heredity  is  often  very  difficult  to  obtain  in  these  cases,  the 
(perhaps  not  unnatural)  conclusion  has  followed  that  environment 
plays  a  very  im-portant  part  in  the  production  of  this  mild  degree 
of  amentia.  That  feeble-mindedness  may  occasionally  so  result  I 
do  not  deny,  but  I  believe  that  the  increased  incidence  of  mental 
defectives  in  towns  is  to  a  great  extent  apparent  only,  and  is 
due  to  the  inclusion  of  a  number  of  children  who  are  not  aments 

at  all. 

In  examining  school-children  in  both  town  and  country,  I  have 
often  been  struck  by  the  fact  that  the  ill-washed,  iU-clad,  and  ill- 
fed — in  short,  the  victims  of  faulty  environment — were  not  as  a 
rule  the  mental  defectives.  In  fact,  such  children  were  often  alert 
and  quick-witted  beyond  the  average,  although  probably  by  no 
means  keen  on  book-learning.  This  fact  led  me  somewhat  to 
discount  environment  as  being  a  frequent  cause  of  amentia.  Next, 
in  examining  certified  mental  defectives  in  special  schools,  I  dis- 
covered a  proportion  of  cases  which  I  had  no  hesitation  in  saying 
were  not  aments  at  all,  but  merely  suffering  from  backwardness, 


Numerical  Incidence  i6i 

and  this  caused  me  to  make  some  inquiries  as  to  the  number  of 
such  children  who  recovered. 

Now,  the  essence  of  mental  defect  is  that  it  is  incurable,  and  by 
no  "  special  "  education,  however  elaborate,  can  a  case  of  amentia 
be  raised  to  the  normal  standard.  Some  defect  must  always  re- 
main, and  upon  this  fact  all  authorities  are  agreed.  When,  there- 
fore, it  is  found  that  a  proportion  of  the  urban  defectives  attending 
special  schools  are  returned  as  cured  to  the  ordinary  schools,  it  is 
•clear  that  an  error  of  diagnosis  has  been  made,  and  that  they  were 
not  defectives.  The  proportion  so  returned  varies  very  much  in 
different  towns,  and  in  many  the  special  classes  have  not  been 
■established  sufficiently  long  to  form  a  reliable  test.  The  following 
is  the  percentage  (of  the  admissions)  of  "  mentally  defective  " 
■children  who  have  so  far  been  returned  cured  to  ordinary  schools 
in  some  towns  in  which  I  made  inquiries:  Birkenhead,  6  per  cent.; 
Bradford,  15  per  cent. ;  Bristol,  3  per  cent. ;  Derby,  5  per  cent. ; 
Leeds,  2  per  cent.;  Leicester,  20  per  cent.;  Liverpool,  4  per  cent.; 
London,  10  per  cent. ;  Nottingham,  10  per  cent. ;  Plymouth,  8  per 
cent. ;  Sheffield,  4  per  cent.  I  think  these  figures  show  conclusively 
that  a  varying,  and  in  some  cases  considerable,  proportion  of  the 
f own  defectives  are  not  aments  at  all.  On  this  point  I  may  quote 
the  opinions  of  two  physicians  who  have  had  large  experience  of 
these  children.  Dr.  Evan  Powell,  of  Nottingham,  writes:  "  I 
agree  with  you  that  a  large  number  of  so-called  defectives  are  in 
reality  not  so,  but  are  merely  suffering  from  temporary  arrest." 
.And  Dr.  Ralph  Crowley,  of  Bradford,  writes:  "  I  have  no  hesitation 
in  saying  that,  where  many  go  back,  the  reason  is  to  be  found  in 
the  fact  that  the  children  in  the  first  place  belonged  to  the  '  merely 
dull  and  backward  group.'  "  In  the  course  of  his  evidence  before 
the  Royal  Commission,  it  was  stated  by  Dr.  Eichholz,  H.M. 
Inspector  of  Special  Schools  under  the  Board  of  Education, 
that,  according  to  his  observations,  from  40  to  50  per  cent,  of 
the  cases  classed  as  "  feeble-minded  "  recovered  under  care  and 
training. 

I  shall  have  occasion  to  refer  again  to  these  cases  of  delayed 
development,  which  simulate  mental  defect,  in  speaking  of  diag- 
nosis; but  I  have  thought  it  well  to  allude  to  them  here  for  the 
reason  that  the  neglect  to  distinguish  them  may  cause  totally 
erroneous  views  as  to  the  increased  prevalence  of  mental  defiiciency 
in  towns,  as  well  as  of  its  cause  and  its  possibility  of  cure.     It  seems 


1 6^  Feeble-Mindedness  in  Children 

to  me  probable  that  the  real  incidence  of  defect  in  town  is  not  much, 
if  any,  greater  than  in  country  districts. 

With  regard  to  the  social  status  of  these  children  there  is  little 
to  be  said.  The  labouring  classes  have  no  monopoly  of  mental 
defect,  and,  although  I  am  unable  to  give  any  actual  figures,  my 
general  impression  is  that  it  is  just  as  prevalent  amongst  the  upper 
as  the  lower  classes  of  this  country. 

With  regard  to  sex,  there  is  a  considerable  preponderance  of 
males,  the  relative  proportion  of  boys  to  girls  being  practically  as 
three  to  two. 

Description. 

Mentally  defective  or  feeble-minded  children  differ  greatly  in  the 
degree  of  their  deficiency.  The  lower  members  of  the  class  closely 
approximate  to,  and  cannot  be  distinctly  separated  from,  the 
imbeciles.  The  higher  members,  on  the  other  hand,  are  but  little 
removed  from  the  merely  dull  and  backward  of  the  normal  popula- 
tion. It  is  therefore  clear  that  no  general  description  can  be  given 
which  would  be  applicable  to  every  mentally  defective  child ;  but 
the  following  are  the  chief  characteristics  of  the  class.  Illustrations 
of  the  milder  degrees  are  shown  in  Plate  II. 

Physical  Condition. — A  small  proportion  of  children  suffering 
from  mental  defect  would  pass  muster  as  normal  if  their  diagnosis 
rested  upon  inspection  only;  but  such  cases  are  exceptional,  and 
the  majority  present  unmistakable  anomalies  of  bodily  structure 
or  function,  as  well  as  of  mental  development. 

Anatomical  anomalies,  or  so-called  stigmata  of  degeneracy,  are 
usually  neither  so  plentiful  nor  pronounced  in  the  feeble-minded 
child  as  in  the  imbecile  or  idiot;  nevertheless  Dr.  Lapage,  as  a 
result  of  his  examination  of  200  children,  found  such  to  occur  in  no- 
less  than  90-5  per  cent,  of  the  total  number  examined.  The  defects 
were  usually  in  combination,  and  in  2373  per  cent,  were  triple. 
In  my  experience  the  cranium  is  the  most  common  site  of  defects,, 
and  I  believe  it  to  be  abnormal  either  in  shape  or  size,  as^Tumetrical, 
bossed,  or  ridged,  in  fully  half  of  these  children.  When  the  child 
first  comes  to  school,  and  between  the  ages  of  seven  and  ten  or 
twelve  years,  the  maximum  circumference  is  usually  about  half  an 
inch  less  than  that  of  a  normal  child  of  corresponding  age  and  sex; 
but  this  discrepancy  becomes  more  and  more  marked,  and  by  the- 
fourteenth  or  sixteenth  year  the  difference  may  be  as  much  as  an. 


Plate  II. 

MENTALLY   DEFECTIVE   SCHOOL-CHILDREN. 


Fig.   10. 


Fig.   II. 


Fig.  12. 


Fig.  13. 


Fig.  I- 


Physical  Condition  163 

inch,  or  even  more.  Next  in  frequency  to  the  cranium,  anomalies 
of  the  palate  are  found;  whilst  malformations  of  the  external  ear 
and  of  the  eye  and  its  appendages  occur  a  little  less  often. 

Inquiries  will  nearly  always  show  that  in  these  children  dentition, 
standing,  walking,  and  speaking  have  been  abnormally  delayed. 
It  may  be  four,  five,  or  even  six  years  before  the  child  says  a  word. 
This  retardation  continues  with  advance  in  years,  so  that  at  every 
period  of  its  school-life  the  mentally  defective  child  compares  un- 
favourabl}^  in  its  bodily  growth  and  acquirements  with  the  one  of 
normal  intellect.  Moreover,  the  bodily  functions  are  often  im- 
perfectly performed :  the  circulation  is  feeble,  so  that  chilblains  and 
sores  are  frequent  in  cold  weather;  assimilation  is  defective,  conse- 
quently the  child  remains  thin  and  ill-nourished;  the  vitality 
generally  is  diminished,  and  catarrhs  and  ill-health  are  exceedingly 
common.  It  was  ascertained  by  Dr.  Ashby  that  the  children  in 
special  schools  at  Manchester  averaged  2  to  4  inches  less  in  height 
and  3  to  12  pounds  less  in  weight  than  the  normal.  To  some  extent 
this  may  be  due  to  the  nature  of  the  environment  in  these  cases. 
As  already  stated,  the  home  conditions  of  the  feeble-minded  are 
often  very  faulty,  and  I  have  usually  found  that  the  defectives  in 
the  country  are  sturdier  and  of  better  physique  than  are  those 
in  the  towns;  but  this  is  not  the  full  explanation,  for  the  same 
applies  to  normal  children,  and,  whatever  their  situation,  mentally 
defective  children  compare  unfavourably  with  their  mentally  sound 
fellows. 

A  hnormalities  of  Nerve  Action  are  very  frequent .  In  some  children 
there  is  a  general  diminution  of  activity,  and  such  are  heavy,  stolid, 
tardy  in  response,  and  laboured  in  all  their  movements.  In  others 
the  reverse  is  the  case,  and  all  movement  is  in  excess.  Such  children 
cannot  sit  or  stand  still ;  they  are  distracted  from  their  task  by  every 
little  thing  around  them,  and  they  are  often  full  of  "  tricks  "  and 

habits. ' '  Co-ordination  of  movement  is  slowly  and  laboriously 
acquired.  The  making  of  pothooks  and  hangers  presents  difficulties 
unknown  to  the  ordinary  child,  and  paper- folding,  card-pricking, 
and  the  simple  kindergarten  occupations  are  in  the  first  instance 
performed  with  a  laborious  clumsiness.  Many  of  the  milder  defec- 
tives, as  a  result  of  special  training,  do  learn  to  use  their  hands 
extremely  well,  but  even  these  rarely  acquire  the  degree  of  dexterity 
attainable  by  an  ordinary  child  who  has  been  similarly  trained. 
In  some  instances  speech  is  accompanied  by  "  spreading  "  action, 


164  Feeble-Mindedness  in  Children 

as  seen  in  corrugation  of   the  forehead,  grinning,  and  at  times 
twitching  of  the  whole  body. 

The  net  result  of  these  anomalies  of  nerve  action  is  a  peculiarity 
of  balance,  movement,  and  physiognomical  expression  which  is 
exceedingly  characteristic  of  the  class,  and  which  frequently  enables 
the  expert  to  detect  mental  deficiency  at  a  glance.  The  expression 
varies  from  a  look  of  heavy,  immobile  stupidity  and  vacuity,  which 
is  chiefly  seen  in  those  lacking  in  action,  to  a  general  restlessness 
and  inattention  to  the  subject  in  hand,  often  accompanied  by 
spasmodic  twitches,  tricks,  and  habits,  which  is  characteristic  of 
those  in  whom  action  is  excessive. 

speech,  as  well  as  being  late  in  making  its  appearance,  is  defec- 
tive in  fully  one-third  of  these  children.  It  is  very  rarely  lacking 
entirely,  although  the  speech  of  some  children,  before  training,  is 
so  imperfect  as  to  be  quite  unintelligible  to  a  stranger.  The  chief 
defects  consist  of  a  thickness  and  indistinctness  of  utterance,  an 
imperfect  articulation  of  consonants,  and  (rarely)  stammering  and 
stuttering.  The  former  of  these  conditions  is  partly  attributable 
to  abnormal  configuration  of  the  palate,  lips,  jaws,  or  pharynx, 
and  partly  to  a  general  brain  inertia  and  inability  or  unwillingness 
to  make  the  effort  necessary  for  distinct  enunciation.  The  con- 
sonantal defects  are  due  to  similar  causes  plus  a  want  of  co-ordina- 
tion. It  may  be  remarked  that  inability  to  pronoimce,  not  one  in 
particular,  but  many  consonants,  is  very  commonly  indicative  of 
mental  deficiency. 

Mental  Condition — Sensation. — In  a  small  proportion  of  these 
children  sensation  is  imperfect  by  reason  of  disease  or  anomalies 
of  the  peripheral  or  central  organs ;  but  on  the  whole  serious  sensory 
defects  are  not  a  prominent  feature  of  the  feeble-minded  degree  of 
amentia.  Defects  of  hearing  (which  are  generally  due  to  disease 
of  the  middle  ear)  are  present  in  about  8  per  cent.,  and  defects  of 
vision  in  about  15  per  cent.,  of  cases.  Colour-blindness,  although 
in  many  cases  seemingly  present,  is  not  in  reality  any  more  common 
than  in  ordinary  children. 

But  there  is  a  great  difference  in  the  educability  of  the  perceptive 
faculties  of  feeble-minded  children.  The  ordinary  healthy  child 
possesses  an  initiative  and  enterprise  which  brings  him  into  daily 
contact  with  sights,  sounds,  and  impressions  of  every  description. 
His  faculties  of  attention  and  curiosity  cause  him  to  observe,  smell, 
and  handle  everything  he  meets,  and  in  consequence  the  range  and 


Mental  Condition  165 

delicacy  of  his  sensorium  soon  becomes  very  considerable.  The 
feeble-minded  child  is  defective  in  many  of  these  qualities;  conse- 
quently the  development  of  his  sensorium  has  to  be  aided  and 
encouraged  by  special  means,  and  until  this  has  been  done  his 
power  of  sensory  discrimination  is  decidedly  inferior  to  that  of  the 
normal  child  of  similar  age.  I  have  frequently  observed  that,  upon 
their  admission  to  a  special  school,  the  sensory  capacity  of  defective 
children  is  comparatively  obtuse,  and  that  they  have  little  ability 
to  discriminate  between  sensory  impressions  of  the  same  order,  but 
of  slightly  differing  intensity.  Under  suitable  training  much  of 
this  is  remedied,  and  the  sensory  functions  of  many  of  the  milder 
types  who  have  been  thus  trained  do  not  seem  to  be  much  inferior 
to  the  normal.  But  the  lower  types  are  lacking  in  this  power  to 
develop,  and  in  them  the  most  persistent  special  training  fails  to 
bring  the  sensorium  up  to  the  normal  level.  In  this  latter  class 
the  organic  sensations  of  pain,  cold,  hunger,  and  discomfort  are 
also  somewhat  obtuse,  but  these  do  not  appear  to  be  so  much  affected 
as  do  the  special  senses. 

Attention. — In  the  lethargic,  inert  type  of  feeble-mindedness  there 
is  a  defect  of  spontaneous  attention ;  but  this  is  never  so  marked  in 
this  degree  as  in  the  more  serious  grades  of  amentia.  The  general 
stir  and  excitement  aroused  by  a  visitor  is  much  more  pronounced 
in  the  special  school  than  in  the  imbecile  ward.  On  the  other  hand, 
active  or  voluntary  attention  is  commonly  in  defect,  both  with 
regard  to  its  intensity  and  its  duration.  The  most  trifling  thing 
serves  to  distract  these  children  from  their  occupation,  so  that  even 
where  the  attention  is  readily  gained,  it  is  with  difficulty  held. 
Many  of  them  become  capable  of  pursuing  a  congenial  task  with  a 
certain  amount  of  patience,  but  the  majority  have  neither  sufficient 
power  of  concentration  or  will  to  be  capable  of  sustained  mental 
effort  against  inclination  or  interposed  obstacles.  They  must  go 
with,  for  they  cannot  fight  against,  the  stream ;  and  this  lack  of  will- 
power and  driving  force  is  one  of  the  most  distinguishing  charac- 
teristics of  aments  at  all  ages. 

School-teachers  often  complain  of  the  lack  of  memory  of  these 
children,  and  if  this  faculty  is  to  be  judged  by  their  inability  to 
remember  items  of  scholastic  knowledge,  there  would  certainly 
appear  to  be  a  decided  deficiency.  Some  of  them  have  very  great 
difficulty  in  connecting  a  word  with  a  thing,  or  in  recognizing  a 
printed  character  or  numeral  as  the  symbol  of  a  concrete  object  or 


1 66  Feeble-Mindedness  in  Children 

number  of  objects.  It  is  the  same  with  colours:  many  can  match 
colours  perfectly  well,  thus  proving  that  their  colour-sense  is  not 
defective,  and  yet  they  may  constantly  confuse  the  names  of  colours. 
It  is  probably  this  which  has  given  rise  to  the  impression  that  colour- 
blindness is  common  amongst  them.  It  is  not  to  be  expected  that 
such  a  child  would  remember  historical  or  geographical  data,  but 
the  defect  seems  to  be  rather  one  of  association  and  comprehension 
of  the  abstract  than  of  memory  proper.  In  the  tenacity  of  their 
memory  for  things  which  are  reaUy  understood,  I  have  been  unable 
to  satisfy  myself  that  feeble-minded  are  at  all  inferior  to  normal 
children,  and  many  of  them  retain  items  of  knowledge  which  have 
been  demonstrated  by  concrete  examples,  as  in  object-lessons, 
remarkably  well. 

As  a  class,  mentally  defective  children  are  imitators  rather  than 
originators.  They  may  faithfully  reproduce,  but  they  rarely  create, 
and  their  faculty  for  evolving  new  ideas — imagination — is  decidedly 
lacking.  But  some  of  them  evince  considerable  cunning  in  the 
commission  of  misdeeds,  as  well  as  no  little  ingenuity  in  the  inven- 
tion of  lies  to  escape  the  consequences;  and  in  many  there  is  abun- 
dant.  evidence  of  the  existence  of  the  day-dreams  and  flights  of 
fancy  which  figure  so  largely  in  the  mental  life  of  the  normal  child. 
I  have  often  seen  them  look  forward  with  delight  to  the  approaching 
Christmas-tree,  and  several  of  my  little  patients  have  taken  me 
into  their  confidence  in  recounting  their  ambition  to  be  a  judge, 
soldier,  sailor,  policeman,  or  engine-driver.  Nevertheless,  the 
fact  remains  that  in  constructive  imagination  and  inventiveness 
there  is  usually  a  considerable  defect. 

Control  is  very  feebly  developed  in  these  children,  and  action 
is  always  along  the  line  of  least  resistance.  Volition  is  by  no  means 
absent,  but  their  behaviour  is  more  often  the  result  of  sudden  desires 
and  impulses  than  of  deliberate  purpose.  They  are  capable  of  such 
simple  feelings  as  pleasure,  pain,  fear,  astonishment,  anger,  sur- 
prise, and  the  like;  but  their  emotions,  like  their  sensations,  are 
usually  weak  and  evanescent.  They  are  rarely  stirred  by  hate,  in- 
dignation, anguish,  awe,  or  a  consciousness  of  the  sublime.  They 
are  readily  amused  by  anything  ridiculous  and  touched  by  anything 
pathetic ;  but  they  have  little  real  sense  of  humour. 

All  of  them  are  lacking  in  the  logical,  and  most  of  them  in  the 
aesthetic,  sense.  In  a  small  proportion  there  is,  in  addition,  a 
marked  deficiency  or  perversion  of  the  moral  sense,  and  such  will 


Scholastic  Acquirements  167 

lie,  pilfer,  and  generally  misconduct  themselves,  without  the  slightest 
compunction.  Some  of  this  type  are  exceedingly  cunning,  and  a 
few  are  guilty  of  acts  of  marked  cruelty  to  other  children  or  to 
dumb  animals.  They  will  also  make  utterly  unfounded  accusa- 
tions with  a  considerable  amount  of  detail  and  appearance  of 
truth.  On  the  other  hand,  there  are  many  who  are  contented, 
obedient,  well-behaved,  and  affectionate,  and  they  may  even  possess 
a  tolerable  conception  of  their  moral  and  religious  obligations. 
Some  are  capable  of  understanding  and  being  influenced  by  simple 
theological  doctrines,  but  on  the  whole  the  religious  sentiment  in 
these  children  is  of  a  decidedly  poor  order. 


Scholastic  Acquirements. 

All  these  children  are  greatly  improved  by  suitable  training, 
but  their  developmental  capacity  and  response  to  education  vary 
enormously.  On  this  account  it  is  convenient  to  divide  them  into 
three  grades. 

The  first  grade  is  composed  of  children  who  make  tolerable  pro- 
gress in  elementary  school  knowledge.  They  are  capable  of  writing 
a  simple  letter,  they  can  read  children's  books,  and  they  can  per- 
form simple  arithmetical  exercises  mentally,  as  well  as  the  first  four 
rules  on  paper.  They  have  a  knowledge  of  money  values,  and  they 
can  be  trusted  with  simple  commissions.  I  have  known  some  of 
them  do  a  quite  creditable  examination  paper  confined  to  simple 
facts  in  history,  geography,  scripture,  etc. ;  but  further  examination 
showed  that  it  was  chiefly  "  parrot  knowledge,"  and  that  they  had 
really  very  little  understanding  of  the  answers  they  had  put  down. 
Their  handiwork  is  often  extremely  good,  and  they  do  little  draw- 
ings, brush-work,  cutting-out,  basket  and  wicker  work,  rug-making, 
and  the  like,  with  a  dexterity  which  is  often  surprising.  They 
have  some  common  sense,  but  they  lack  resource  and  judgment 
and  often  initiative. 

The  second  grade  fall  considerably  behind  the  former  in  purely 
scholastic  attainments,  and  also,  although  not  to  the  same  extent, 
in  handicraft.  They  are  rarely  capable  of  mental,  and  seldom  of 
paper,  arithmetic,  and  their  reading  and  writing  ability  extends 
no  further  than  simple  words  of  one  syllable.  Some  are  even  unable 
to  do  this. 

They  can  perform  the  same  kind  of  manual  work,  but  the  result 


1 68  Feeble-Mindedness  in   Children 

is  not  nearly  so  good,  and  they  require  more  constant  stimulation 
as  well  as  much  closer  supervision.  They  have  decidedly  less 
general  intelligence. 

The  third  grade  form  a  connecting  link  with  the  imbeciles,  from 
whom,  indeed,  they  are  but  little  removed.  The  improvement 
effected  by  the  special  school  is  limited  to  the  development  of  some 
capacity  for  manual  work  under  supervision,  and  to  the  formation 
of  habits  of  obedience,  tidiness,  and  regularity.  Their  scholastic 
acquirements  are  practically  nil. 

As  a  concrete  example  of  the  difference  between  mentally  defec- 
tive and  normal  school-children,  I  may  give  the  following  brief 
account  of  the  pupils  attending  a  typical  "  special  "  day-school 
under  the  London  County  Coimcil. 

This  school*  contains  over  sixty  defective  boys  and  girls,  who 
are  divided  into  three  separate  classes,  each  under  a  mistress.  In 
the  lowest  class  the  average  age  of  the  children  is  from  eight  to  nine 
years,  the  youngest  being  seven  and  the  oldest  about  twelve  years. 
In  age,  therefore,  they  correspond  approximately  to  normal 
Standard  II.,  in  which  the  school- work  consists  of — Reading 
equivalent  to  ^sop's  "  Fables."  Writing  :  transcription  and  dicta- 
tion equal  to  the  same.  Arithmetic  :  tables  up  to  12  x  12;  pence 
table ;  compound  addition,  subtraction,  multiplication,  and  division ; 
four  simple  rules  and  problems  introducing  two  or  more  rules  at 
one  time.  Drawing :  simple  freehand,  use  of  ruler  and  set-square. 
Geography.  History.  Object-lessons  in  animal  and  vegetable  life 
and  simple  science. 

The  work  actually  done  by  the  defective  children  in  this  class 
consists  of  recognition  of  letters  of  the  alphabet  and  reading  words 
of  three  or  four  letters;  transcription  of  the  same  from  a  black- 
board copy;  recognition  of  simple  numerals,  and  writing  the  same 
from  dictation ;  simple  addition  up  to  ten  and  simple  subtraction  of 
single  figures.  None  are  capable  of  writing  from  dictation,  and  all 
sums  are  done  in  the  concrete  by  means  of  beads  or  tablets.  In 
addition,  the  children  are  taught  the  use  of  the  ruler;  they  learn 
simple  paper  folding  and  cutting,  brush-work,  and  rough  clay 
modelling.     They  also  engage  in  musical  drill  and  games. 

The  average  defective  child  takes  two  years  before  he  or  she 
becomes  proficient  enough  to  be  passed  out  of  this  class.     Some 

*  Goodrich  Road  Special  School,  East  Duhvich,  S.E.,  in  the  charge  of 
Miss  N.  Mumbray. 


Scholastic  Acquirements  169 

never  do  attain  to  this  proficiency,  although  they  may  be  moved 
up  on  account  of  their  size.  A  few  are  sufficiently  advanced  to  be 
transferred  after  six  months,  but  I  am  of  opinion  that  the  majority 
of  these  are  not  really  defective,  but  merely  dull  and  backward. 

In  the  middle  class  the  average  age  is  from  ten  to  eleven,  the 
youngest  being  eight  and  the  oldest  sixteen  years.  It  thus  corre- 
sponds to  normal  Standard  IV.,  in  which  the  work  consists  of — • 
Reading  from  Geographical,  Historical,  and  Literary  Readers. 
Writing,  the  same,  with  short  essays  and  letter- writing.  Arith- 
metic :  simple  exercises  in  money,  time,  weights  and  measures; 
simple  vulgar  and  decimal  fractions.  Geography,  History,  Grammar, 
Object-lessons,  and  Drawing,  all  more  advanced. 

The  work  actually  done  in  this  class  is  reading  simple  words  of 
one  and  two  syllables  from  Infant  Reader  I. ;  transcription  and 
dictation  in  simple  words  of  one  and  two  syllables;  addition,  in  the 
abstract,  of  simple  numbers  up  to  100 ;  subtraction  of  tens  and  units ; 
simple  multiplication  and,  rarely,  simple  division  by  one  figure. 
The  occupations  consist  of  rather  more  advanced  brush-work,  paper- 
folding  and  threading,  cutting  paper  in  the  form  of  leaves  for 
flower-making,  and  clay-modelling.  The  average  time  spent  in  this 
class  is  about  two  j^ears. 

In  the  highest  class  the  average  age  is  twelve  years,  the  youngest 
being  ten  and  the  oldest  nearly  sixteen.  One-fourth  of  the  pupils 
are  over  thirteen.  They  thus  correspond  in  age  with  Standards  VI. 
and  VII.,  in  which  the  school-work  consists  of — Reading  from 
more  advanced  Literary,  Geographical,  and  Historical  Readers. 
Writing,  the  same,  with  short  original  essays  on  geographical  and 
historical  topics.  Arithmetic:  simple  and  compound  practice; 
problems  in  greatest  common  measure  and  least  common  multiple ; 
the  first  four  rules  in  vulgar  and  decimal  fractions.  Grammar,  with 
analysis  and  parsing.  More  advanced  History  and  Geography. 
Geometry  and  Model-drawing.  Elementary  lessons  in  Physics  and 
Chemistry. 

The  work  done  by  this  class  consists  of  reading  and  writing, 
equivalent  to  normal  Standard  II. :  compound  addition  and  sub- 
traction up  to  1,000,  and  simple  rnxultiplication  and  division.  Ex- 
cluding a  few  children — who,  in  my  opinion,  are  not  really  defec- 
tive— it  may  be  said  that  the  scholastic  acquirements  of  none  of 
these  children  come  up  to  normal  Standard  II.  In  occupations 
and  manual  work  they  are  decidedly  better,  and  a  considerable 


170  Feeble-Mindedness  in  Children 

proportion  of  the  children  in  this  class  can  cut  out  and  make  simple 
artificial  flowers,  knit  rugs  and  weave  baskets,  with  a  really  very 
creditable  amount  of  dexterity,  which  redounds  in  no  slight  measure 
to  the  patient,  persevering,  and  systematic  care  of  their  teacher. 

With  the  object  of  testing  their  capacity  for  attention,  memory, 
and  general  comprehension.  Miss  Mumbray  was  good  enough  to 
place  for  me  a  collection  of  twelve  small  articles,  such  as  a  pencil, 
tape,  bottle,  scissors,  etc.,  on  a  board,  and  let  the  children  look  at 
them  for  two  minutes.  The  board  was  then  removed,  and  the 
children  given  ten  minutes  in  which  to  write  down,  either  in  words 
or  graphically,  the  things  they  had  seen.  Out  of  eighteen  com- 
petitors, all  but  one  found  it  easier  to  draw  than  to  write  the  names 
of  the  objects;  five  children  remembered  the  whole  twelve  articles, 
four  remembered  eleven,  four  ten,  one  nine,  one  eight,  two  seven, 
and  one  only  five.  In  the  majority  of  the  children  the  drawings 
were  sufficiently  good  to  enable  me  to  readily  recognize  the  Several 
objects  for  which  they  were  intended,  whilst  some  were  really 
excellent. 

There  is  no  doubt  that,  for  the  majority  of  these  children,  a 
residential  school  produces  far  more  satisfactory  results  than  does 
a  day-school.  For  the  pupils  in  the  former  are  under  more  con- 
stant supervision,  and  can  receive  instruction  in  dressing,  feeding, 
personal  cleanliness  and  tidiness,  which  have  the  utmost  educa- 
tional value.  Moreover,  they  make  more  definite  companionships, 
and  stimulate  one  another  during  play  and  work  in  a  way  which  is 
impossible  at  a  day-school.  One  of  the  earliest  residential  schools 
of  this  kind  is  Littleton  House,  at  Uxbridge,  established  in  1902 
through  the  energy,  and  to  a  very  great  extent  personal  generosity, 
of  Miss  Douglas  Townsend,  whose  labours  in  connexion  with  the 
feeble-minded  are  well  known.  This  school  contains  twenty-four 
boys,  ranging  in  age  from  seven  to  sixteen  years.  The  scholastic 
work  done  is  similar  to  that  already  described,  but  in  addition  the 
boys  have  a  good-sized  garden,  in  which  each  has  his  own  little  plot 
to  do  exactly  as  he  likes  with.  There  is  a  carpenter's  shop,  where 
they  learn  to  make  many  useful  articles,  and  several  of  them  keep 
and  look  after  pet  animals,  whilst  under  the  direction  of  the  matron 
they  learn  to  do  most  of  the  house-work,  in  which  they  take  a  keen 
delight.  Miss  Townsend  and  the  managers  fully  recognize  that 
defective  children  learn  more  through  their  hands  than  through 
books;  consequently  manual  instruction  is  a  very  important  feature 


Plate  III. 


To/nce  ^agc  170. 


Scholastic  Acquirements  171 

of  the  school,  occupying  half  the  working-day  and  being  super- 
intended by  a  special  manual  instructor.  In  addition  to  this,  the 
boys  are  trained  to  go  messages  and  execute  simple  commissions, 
which  most  of  them  soon  learn  to  do  very  faithfully.  But  the 
most  noteworthy  feature  of  the  establishment,  and  one  which  I 
certainly  think  has  proved  of  extraordinary  educational  value,  is 
the  formation  of  a  troop  of  Baden-Powell  Scouts,  for  the  inception 
and  running  of  which  the  school  is  indebted  to  the  able  master, 
Mr.  R.  Parkinson.  This  troop  goes  into  camp  for  a  period  of  four 
weeks  each  year,  during  which  the  boys  are  not  only  thoroughly 
well  behaved,  but  pitch  their  tents,  cook  their  food,  and  engage  in 
drills  and  long  route  marches,  just  the  same  as  an  ordinary  troop. 
Mr.  Parkinson  has  even  organized  a  combined  drill  and  gymnastic 
display  which  has  been  publicly  performed  on  many  occasions 
with  great  eclat.  There  was  some  little  difficulty  in  obtaining 
official  recognition  of  the  troop  in  the  first  instance,  but  of  the 
twenty-four  boys,  there  are  twelve  who  now  hold  naturalist's  badges, 
three  patrol  leaders,  three  second-class  scouts,  three  with  bugler's 
badges,  three  with  carpenter's  badges,  and  two  cooks.  It  must 
be  admitted  that  the  moving  spirits  of  the  troop  are  two  or  three 
boys,  who,  although  coming  within  the  definition  of  the  Act  in 
their  inability  to  profit  by  ordinary  school  instruction,  have  now  im- 
proved to  a  very  great  extent,  and  are  probably  not  really  aments; 
but  the  remainder  have  been  by  this  means  not  only  greatly  im- 
proved in  their  physique,  but  have  developed  attention,  observa- 
tion, and  keenness,  have  learned  discipline,  and  have  made  great 
strides  in  general  mental  development  and  in  the  capacity  for 
■concerted  and  co-ordinated  action  as  component  individuals  of 
their  own  little  community.  I  regard  it  as  an  experiment  in  the 
■education  of  mentally  defective  children  which  has  been  attended 
with  conspicuous  success  (see  Plate  III.). 

Such  are  the  chief  abilities  and  disabilities  of  mentally  defective 
children.  They  differ,  however,  not  only  in  the  degree  of  their 
deficiency,  but  also  in  their  temperament,  disposition,  and  general 
behaviour.  In  fact,  they  possess  individuality  just  as  do  normal 
children,  although  this  is  not  as  a  rule  a  pronounced  and  dominating 
feature  until  after  puberty.  Moreover,  there  are  certain  readily 
recognizable  clinical  types  of  these  children,  just  as  there  are  of 
aments  in  general,  whilst  superadded  complications  are  not  un- 
common.    The  great  majority  suffer  from  primary  amentia,  and 


1/2  Feeble-Mindedness  in  Children 

although  most  of  these  are  of  the  simple  variety,  between  5  and 
10  per  cent,  are  microcephalics,  about  2  or  3  per  cent,  macro- 
cephalics,  and  about  the  same  number  are  of  the  Mongolian  variety. 
In  probably  about  10  to  15  per  cent,  of  these  children  the  amentia 
is  of  the  secondary  form,  most  of  them  being  of  the  vascular  or 
post-febrile  varieties.  In  a  small  proportion  of  these  some  degree 
of  paresis  or  paralysis  is  present,  although  this  is  neither  so  prevalent 
nor  so  severe  as  in  the  imbeciles  and  idiots.  Another  small  pro- 
portion are  cretins,  and  in  a  still  smaller  number  there  is  evidence  of 
syphilis.  Indications  of  rickets  are  not  uncommon,  whilst  in  about 
10  per  cent,  of  cases  the  feeble-mindedness  is  accompanied  by 
epilepsy. 

But  whatever  the  particular  features  may  be,  there  is  one  quality 
which  characterizes  all  the  varieties  and  grades  of  these  children, 
and  that  is  their  inability  to  swim  against  the  stream,  or  even  to 
keep  their  heads  above  water,  without  the  assistance  of  some  kindly 
hand.  Whilst  the  ordinary  child  of  fourteen  or  sixteen  years  has 
not  only  a  considerable  knowledge  of  common  things  and  events, 
but  has  in  addition  acquired  notions  of  qualities  and  conceptions 
of  the  abstract ;  whilst  he  has  developed  the  faculty  of  comparing, 
relating,  and  judging  between  these  conceptions,  and  of  tracing  a 
connexion  between  cause  and  effect;  whilst  his  mind  now  enables 
him  to  take  an  intelligent  interest  in  his  daily  work,  and  allows  him 
to  shape  plans  for  his  future;  whilst,  in  short,  he  has  learned  to  put 
away  childish  things  and  has  become  capable  of  standing  alone — 
the  mentally  defective  one  of  similar  age  is  still  happy  with  his 
toys,  and  his  whole  behaviour  and  conversation  still  indicate  the 
infantile  and  imperfect  character  of  his  mind.  Bodily  and  mentally 
he  is  always  in  arrears,  and  with  each  advancing  year  his  intellect 
is  left  farther  and  farther  behind  that  of  his  more  fortunate  fellow. 
His  special  training  has  done  much  for  him,  in  so  far  as  it  has  in- 
culcated habits  of  regularity  and  conformity  to  the  will  of  others; 
further,  and  more  important,  because  it  has  converted  him  from  a 
useless,  and  often  dangerous,  member  of  society  into  one  capable 
of  some  amount  of  useful  work.  But  this  latter  can  only  be  accom- 
plished under  supervision,  and  the  future  of  the  feeble-minded  child, 
as  he  passes  out  of  the  door  of  the  school  for  the  last  time  into  the 
great  world  beyond,  will  entirely  depend  upon  how  thorough  and 
careful  this  supervision  is. 


CHAPTER  IX 
FEEBLE-MINDEDNESS  IN  ADULTS 

Definition. — The  term  feeble-minded  person  is  applied  to  an 
individual  suffering  from  the  mildest  degree  of  amentia  who  is 
over  the  age  of  sixteen  years,  those  under  this  age  being  known 
as  "  mentally  defective  children." 

The  definition  suggested  by  the  Royal  College  of  Physicians  of 
the  feeble-minded  person,  and  adopted  in  a  former  edition  of  this 
book,  was  "  one  who  is  capable  of  earning  a  living  under  favourable 
circumstances,  but  is  incapable,  from  mental  defect  existing  from 
birth  or  from  an  early  age,  {a)  of  competing  on  equal  terms  with  his 
normal  fellows,  or  {h)  of  managing  himself  and  his  affairs  with 
ordinary  prudence." 

This,  however,  has  now  been  superseded,  and  the  legal  definition 
as  given  in  Clause  L  of  the  Mental  Deficiency  Act  of  19 13  is: 

"Persons  in  whose  case  there  exists  from  birth  or  from  an  early  age 
mental  defectiveness  not  amounting  to  imbecility,  yet  so  pronounced 
that  they  require  care,  supervision,  and  control  for  their  own  protection 
or  for  the  protection  of  others." 

Number. — The  inquiries  of  the  Royal  Commission  show  that 
about  40  per  cent,  of  all  aments  in  this  country  are  feeble-minded 
persons,  and  I  have  calculated  that  in  England  and  Wales  on 
January  i,  1906,  their  approximate  total  was  54,114.  This  number 
is  rather  less  than  half  the  total  insane  on  the  same  date,  and 
corresponds  to  1-57  feeble-minded  persons  in  every  1,000  popula- 
tion. But  the  incidence  is  not  uniform  throughout  the  country ; 
it  varies  directly  with  the  prevalence  of  mental  abnormality  in 
general  (which  is  subject  to  a  very  considerable  range  of  variation) ; 
it  also  differs  according  to  the  environment.  The  prevalence  in 
the  respective  areas  investigated  has  been  shown  in  Tables  L  and 
TV.,  pp.  12  and  16,  from  which  it  is  seen  that  the  feeble-minded  adult, 

173 


174  Feeble- Mindedn ess  in  Adults 

both  absolutely  and  relatively,  tends  to  be  commoner  in  agricultural 
than  in  urban  districts. 

The  cause  of  this  is  not  at  first  sight  clear,  for  these  persons  are 
but  grown-up  defective  children,  and  this  latter  class  is  apparently 
much  more  numerous  in  the  towns  than  in  the  country.  As  I  have 
shown,  however,  there  is  good  reason  for  thinking  that  a  large 
proportion  of  the  so-called  mentally  defective  children  of  our  towns 
are  not  defective  at  all,  but  simply  suffering  from  delayed  develop- 
ment ;  so  that  the  real  incidence  of  mentally  defective  children  is 
probably  not  appreciably  greater  in  urban  than  in  rural  areas.  In 
addition,  the  increased  competition  of  town  life  is  decidedly  un- 
favourable to  the  feeble-minded  adult,  and  there  is  evidence  to 
show  that  as  a  consequence  a  certain  number  of  those  born  in  towns 
are  gradually  squeezed  out  into  the  country. 

Sex. — On  the  whole,  males  and  females  occur  to  about  an  equal 
extent,  and  the  investigations  of  the  Royal  Commission  show  that, 
of  a  total  of  4,291  feeble-minded  persons,  2,179  were  males  and 
2,112  were  females. 


Description. 

Physical  and  Mental  Characteristics. — It  has  been  well  said  that 
"  the  child  is  father  to  the  man,"  and  in  the  main  the  physical  and 
mental  characteristics  of  the  feeble-minded  adult  are  similar  to 
those  of  the  mentally  defective  child ;  but  a  few  points  of  difference 
must  be  noticed. 

With  regard  to  their  physical  condition,  the  anatomical  stigmata 
of  degeneracy  of  course  persist,  whilst  defects  of  stature  and  general 
development  tend  to  become  even  more  noticeable  as  the  years 
advance,  in  comparison  with  the  normal  adult.  On  the  other  hand, 
a  certain  amount  of  improvement  of  function  has  taken  place,  so 
that  the  bodily  nutrition  is  better,  and  the  proneness  to  ailments 
not  nearly  so  marked.  Nevertheless,  the  expectation  of  life  in  the 
feeble-minded  is  decidedly  less  than  in  the  ordinary  population. 
Improvement  is  also  usually  seen  in  nerve  action,  and  although 
the  diminution  or  excess  of  movement  which  characterized  the 
child  is  still  a  feature  of  the  adult,  and  the  balance  and  carriage  of 
the  body  are  often  still  clumsy  and  ungainly,  the  adult  has,  with  the 
practice  resulting  from  years  of  experience,  gradually  acquired  a 
certain  amount  of  muscular  control.     As  a  consequence,  the  tricks, 


Physical  and   Mental   Characteristics  175 

habits,  and  often  marked  inco-ordination  of  the  child  are  less 
frequently  seen  in  the  adult. 

Similarly  with  the  mental  condition.  A  certain  amount  of  savoir- 
faire  is  acquired  by  experience,  and  mental  action  generally  may 
have  been  considerably  improved  by  special  training.  But  the 
capacity  of  these  persons  only  extends  to  the  things  with  which  they 
are  familiar,  and  they  cannot  rise  to  any  work  or  circumstances 
outside  their  daily  routine.  They  still  show  the  same  lack  of 
observation  and  reasoning  power,  they  have  little  ability  to  general- 
ize or  to  apply  their  limited  knowledge  to  new  conditions,  and  their 
ideas  still  retain  much  of  the  crudity  of  childhood.  It  results  from 
this  that,  although  the  feeble-minded  adult  may  be,  and  often  is, 
capable  of  useful  employment  of  a  routine  nature  under  supervision, 
he  is  as  a  rule  incapable  of  steering  his  own  course,  or  even  of 
providing  for  himself  without  some  assistance.  And  when  con- 
trasted with  a  normal  individual  of  similar  age,  his  lack  of  mental 
capacity  is  even  more  prominent  than  in  the  case  of  the  defective 
child. 

On  the  whole,  I  think  that  the  foregoing  description  is  applicable 
to  the  bulk  of  the  feeble-minded;  but  it  must  be  remembered  that 
there  are  many  degrees,  and  that  no  account  can  be  given  which 
would  fit  every  member  of  the  class.  This  description  is  probably 
too  flattering  to  some  of  the  more  pronounced  defectives;  on  the 
other  hand,  to  the  highest  types  of  all  such  an  account  may  be 
somewhat  unfair,  for  many  of  these  are  tolerably  well  grown  and 
developed,  and  show  little  indication  of  their  weakness  if  they  are 
not  scrutinized  too  carefully.  Those  of  this  mild  grade  belonging 
to  the  upper  and  wealthier  classes — ^for  poverty  has  no  monopoly 
of  feeble-mindedness — do  not  usually  find  the  daily  round  of  society 
beyond  their  capacity;  they  even  marry  or  are  given  in  marriage, 
and  it  is  only  when  a  situation  arises  which  calls  for  management 
and  judgment  that  their  defect  becomes  patent.  So  long  as  they 
are  under  supervision  they  pass  muster,  but  once  let  them  take  the 
reins,  and  chaotic  disaster  speedily  results. 

It  is,  however,  rather  in  the  matter  of  character  that  the  greatest 
difference  exists  between  the  grown-up  and  juvenile  feeble-minded. 
Ordinary  persons  approximate  to  one  common  type  much  more  in 
childhood  than  in  adult  life,  and  although  individual  differences  are 
observable  from  the  first  few  weeks  of  life,  they  become  much  more 
pronounced  about  the  age  of  puberty.     So  it  is  with  the  feeble- 


176  Feeble-Mindedness  in  Adults 

minded.  The  advent  of  puberty  often  sees  the  evolution  of  habits 
and  propensities  which  have  the  greatest  effect  upon  the  future 
life,  and  which  have  hitherto  been  latent.  Possibly  to  a  consider- 
able extent  these  may  be  dependent  upon  the  early  environment 
and  training,  or  absence  of  training;  but  heredity  often  plays  an 
important  part,  as  in  the  ordinary  child.  Whatever  their  origin, 
the  mental  defect  and  lessened  power  of  control  of  these  persons 
tend  to  bring  these  habits  and  propensities  into  extreme  prom- 
inence. 

These  propensities  are  many  and  varied,  and  from  the  point  of 
view  of  administration  they  demand  the  closest  attention.  Indeed, 
I  would  go  so  far  as  to  say  that,  in  dealing  with  the  feeble-minded, 
there  could  be  no  greater  administrative  blunder  than  to  treat 
mental  defect  in  the  abstract,  and  pay  no-regard  to  these  peculiari- 
ties of  the  individual.  Some  feeble-minded  persons  are  placid, 
well-behaved,  and  industrious;  others  are  perfectly  harmless,  but 
possess  pronounced  wandering  proclivities;  others  are  exceedingly 
facile;  whilst  yet  others  have  a  strong  predisposition  to  insanity 
or  crime.  On  the  whole,  I  think  that  all  of  them  may  be  divided 
into  two  main  classes,  according  as  their  mental  equilibrium  tends 
to  be  stable  or  unstable,  and  these  we  may  briefly  describe. 

Feeble-minded  of  Stable  Mental  Equilibrium. — Many  feeble- 
minded persons  are  quiet,  placid,  inoffensive,  and  good-natured 
individuals  who  go  on  their  way  comparatively  unmoved  by  the 
happenings  of  life.  They  are  not  insensible  to  pleasure,  and  they 
evince  a  certain  amount  of  delight,  just  as  would  a  child,  at  a 
theatre,  a  circus,  the  sight  of  a  company  of  soldiers,  or  the  like. 
They  are  also  conscious  of,  and  affected  by,  praise,  rebuke,  or  ill- 
treatment;  but  their  joy  or  sorrow  is  neither  excessive  nor  of  long 
duration,  and  their  general  demeanour  is  that  of  happy  placidity. 
The  mental  constitution  of  such  persons  is  in  striking  contrast  to 
that  of  the  class  we  shall  next  consider,  and  they  may  be  appro- 
priately designated  as  of  stable  equilibrium.  I  can  give  no  precise 
figures,  but  my  impression  is  that  this  t3^e  comprises  about  30  to 
40  per  cent,  of  all  the  feeble-minded.  Owing  to  the  present  lack 
of  organization  for  providing  these  persons  with  suitable  employ- 
ment, a  considerable  number  of  them  are  idle,  and  spend  their  time 
roaming  the  villages  and  country  lanes;  but  most  of  these  will 
cheerfully  carry  a  parcel  or  do  any  odd  jobs  they  may  be  asked  to 
do,  and  those  for  whom  continuous  employment  is  found  prove 


Plate  IV. 


To  face  page  176.] 


Mentally  Stable  Type  .177 

themselves  to  be   steady,    industrious  workers.     Illustrations   of 
this  type  are  shown  in  Plate  IV. 

In  the  country  a  certain  number  of  them  are  employed  upon  the 
land  in  some  simple  capacity,  such  as  helping  with  the  hay  or  corn, 
the  plough  or  roots,  scaring  the  birds,  or  bringing  up  the  cows; 
and  although  they  cannot  be  trusted  to  do  the  full  work  of  an 
agricultural  labourer,  they  often  take  the  place  of  a  boy  to  the 
satisfaction  of  their  employer,  and  they  are  quite  worth  their  keep 
and  the  shilling  or  two  a  week  they  receive.  It  is  probable  that 
most  moderate-sized  villages  possess  at  least  one  of  these  "  softies," 
■"  naturals,"  "  dafties,"  or  "  not  exactlies,"  as  they  are  called;  and 
although  they  are  at  times  made  fun  of  by  the  urchins  of  the  place, 
they  are  not,  as  a  rule,  unkindly  treated.  In  the  towns,  on  the 
other  hand,  this  type  is  not  nearly  so  common.  Such  persons  may 
occasionally  be  seen  selling  newspapers,  distributing  bills,  hawking 
firewood,  or  doing  odd  jobs  for  some  charitably  disposed  person; 
but  the  increased  competition  of  town  life  is  decidedly  against  them, 
and  they  rapidly  tend  to  be  squeezed  farther  afield  or  to  gravitate 
into  the  workhouse  or  some  charitable  institution. 

The  life  of  these  persons  is  one  of  conformity  to  habit,  and  not 
to  ideals.  They  rarely  think  of,  much  less  make  plans  for,  the 
future;  and  the  few  who  have  vain  imaginations  as  to  what  they 
would  like  to  do  or  become  are  lacking  in  the  necessary  intelligence 
or  will  to  direct  their  actions  accordingly.  Indeed,  one  of  the  most 
pronounced  features  of  the  feeble-minded  person  is  his  utter  lack 
of  purpose.  If  given  work  and  told  exactly  what  to  do,  he  may 
often  be  trusted  to  do  it;  he  may  even  acquire  the  habit  of  per- 
forming the  same  task  day  after  day,  year  in  and  year  out,  without 
supervision.  But  the  work  must  be  strictly  of  a  routine  nature, 
for  he  would  be  quite  unable  to  cope  with  any  unforeseen  occur- 
rence. And  should  he  lose  his  employment,  he  is  incapable  of  any 
strenuous  attempt  to  seek  more.  To  use  a  homely  phrase,  we  may 
say  that  the  bread  of  these  persons  must  be  put  into  their  mouths. 

The  following  are  fairly  typical  illustrations  of  this  stable  type  of 
feeble-mindedness : 

A.  C.  is  a  man  of  twenty-two  years,  although  he  looks  only  about 
seventeen.  He  went  to  an  ordinary  elementary  school,  and  was 
in  the  sixth  standard  when  he  left ;  but  his  schoolmaster  tells  me 
that  he  was  only  moved  up  each  year  on  account  of  his  size  and 
age,  and  that  his  scholastic  attainments  were  really  only  equal  to 


178  Feeble-Mindedness  in  Adults 

Standard  III.     During  the   two   years   following  school  he  had 
several  situations,  mostly  as  errand-boy,  but  he  was  discharged 
from  each  place  in  turn  on  account  of  general  incompetence.     Then 
he  was  taken,  largely  from  philanthropic  motives,  into  a  printing- 
office,  and  there  he  has  remained  until  the  present  time.     His  work 
is   purely  mechanical,   and  consists   in  helping  a  man  with  the 
machine,  carrying  bales  of  paper,  and  so  on.     He  began  with  a 
wage  of  nine  shillings  weekly ;  this  has  been  increased,  and  he  now 
has  a  standing  wage  of  eleven  shillings,  but  he  often  puts  in  over- 
time, and  he  usually  earns  about  thirteen  shillings.     He  lives  at 
home  with  his  parents,  and  he  gives  his  money  to  his  mother,  who 
allows  him  a  shilling  weekly  as  pocket-money.     When  clothing  or 
boots  are  required,  his  mother  buys  them,  and,  in  fact,  he  is  treated 
exactly  as  a  child.     He  is  perfectly  happy  and  contented  with  his 
lot,  and  has  no  ambition  to  be  other  than  what  he  is ;  but  it  is  diffi- 
cult to  say  what  is  going  to  happen  when  he  has  no  home  to  go  to 
and  no  parents  to  look  after  him.     I  asked  him  if  he  had  ever 
thought  of  getting  married.     He  said:  "  No."     I  asked  him  if  he 
ever  kept  company  with  anyone.     He  said  he  did  for  a  time,  and 
used  to  "  walk  out  "  with  a  girl  every  night.     To  my  questions 
as  to  what  he  used  to  say  to  her,  he  said:  "  She  used  to  ask  me  how 
I  was  getting  on  at  my  "work.     I  said:  '  Pretty  fair.'     I  used  to  ask 
her  how  she  was  getting  on  at  her  work.     She  said:  'All  right.'  " 
There  do  not  appear  to  have  been  many  love-passages,  for  he  admits 
that  he  never  kissed  her.     After  six  months  the  maiden  tired,  and 
she  now  walks  out  with  one  of  his  more  enterprising  mates.     This 
youth  once  conceived  the  desire  to  join  the  Volunteers,  and  applied 
to   the    local   non-commissioned   officer.     The    Sergeant-Ma j or,    a 
shrewd  man  and  a  good  judge  of  men,  rejected  him,  and,  when 
I   asked  if  he   didn't   come  up   to   the   physical   standard,    said: 
"  His  body  was  all  right,  sir;  but  he  had  too  little  brain-pan."     He 
has  a  few  stigmata,  can  read  and  write  tolerably  well,  and  can  da 
simple  sums ;  he  can  also  copy  drawing  very  creditably,  but  he  has 
little  other  knowledge.     After  a  good  deal  of  consideration,  he  told 
me  that  history  was  "  what  happened  before, "  and  that  geography 
was  "  about  towns  and  rivers,"  but  he  has  no  historical  or  geo- 
graphical knowledge.     I  asked  him  which  was  the  first  war  that  he 
learned   about.     After  much   cogitation   he   said:    "  It   was   near 
Trafalgar  Day.     It  was  when  Nelson  fought.     He  defeated  the 
Spaniards."     On  being  asked  how  long  ago  that  happened,  after  a 


Illustrative  Cases 


79 


very  long  pause  he  said:  "  From  then  to  now,  do  you  mean  ?"  and, 
on  my  replying  in  the  affirmative,  said:  "  About  seven  hundred." 
His  knowledge  of  geography  was  of  the  same  order,  and  although 
he  told  me  he  had  got  a  Sunday-school  prize,  to  my  query  as  to 
who  God  was  he  replied,  after  much  thought :  "  The  Son  of  man." 

Frank  C.  This  patient  is  the  son  of  a  country  gentleman,  and 
was  mentally  and  physically  backward  from  birth.  He  did  not 
walk  until  in  his  fourth  year,  and  did  not  talk  until  turned  five. 
During  the  whole  of  childhood  he  was  exceedingly  delicate,  nervous, 
and  excitable,  suffering  constantly  from  asthma,  bronchitis,  and 
laryngismus.  He  went  to  a  private  school  at  the  age  of  eight  years, 
but  never  got  on;  he  was  tried  at  several  other  schools,  but  was 
found  incapable  of  making  scholastic  progress.  During  his  ninth 
year  he  began  to  masturbate,  and  he  has  practised  this  constantly 
ever  since.  At  twelve  years  of  age  he  was  placed  for  a  time  in  the 
house  of  a  mental  specialist.  From  this  he  was  removed  to  be 
boarded  out  with  a  clergyman  for  two  years;  but  was  taken  away 
because  his  parents  thought  his  host  was  inculcating  too  much 
ritualism.  He  was  then  boarded  out  with  a  farmer  for  a  period  of 
five  years,  and  spent  his  time  helping  with  the  cattle,  horses,  and 
farm-work  generally.  In  this  situation  he  seemed  to  improve  so 
much  that  he  was.  brought  home  with  the  idea  that  he  might  now 
remain  and  potter  about  on  his  father's  estate.  After  being  home  for 
a  few  months,  however,  he  caused  general  consternation  by  sud- 
denly announcing  his  intention  of  marrying  one  of  the  maids  in  the 
house.  He  had  skid  nothing  at  all  to  the  girl,  who  seemed  exceed- 
ingly quiet  and  respectable,  and  had  not  encouraged  him  in  any 
way,  and  the  first  intimation  of  his  feelings  was  the  receipt  by  the 
girl's  mother  of  the  following  letter; 

October  ist,  19010, 
Saturday. 
Dear  Mrs.  S -, 

/  am  writing  to  inform  you  that  I  intend  to  have  your  daughter 
Fanney  to  become  my  wife  and  I  sencerely  hope  that  you  wont  refuse 
me  you  may  be  quite  sure  that  I  shall  take  great  care  of  her  and~I 
promise  that  she  shall  have  all  that  she  wants  as  far  as  our  means  will 
let  us  But  I  give  you  fair  warning  that  if  you  refuse  me  I  shall  take 
her  without  your  consent  as  I  am  determent  to  have  Fanney  my  people 

will  make  a  big  row  over  this  but  you  must  take  no  notice  of  that  but  be 


i8o  Feeble-Mindedness  in  Adults 

equality  determent  for  me  to  have  her  if  anything  is  said  about  it 

Believe  me  to  be  yours  sencerely 

Frank . 

Fanney  knows  me  quite  well  as  we  have  seen  each  other  at  home. 
By  this  mark  I  promise  to  do  all  that  I  have  said  in  this  letter. 

(Two  blobs  of  sealing  wax  here.) 
Whatever  may  happen  nothing  shall  part  us  but  death  and  that  only. 

At  the  same  time  the  vicar  received  the  following : 

October  ist,  19010, 

Saturday. 

Mr.  W . 

Dear,  Sir 

Will  you  kindly  call  my  bands  between  Miss  Fanney  S 


of  B and  Frank  C of .     //  you  refuse  to  call  it  I  shall 

find  some  other  means  of  having  it  done  or  I  shall  get  some  one  else  to 
call  it  in  the  Chttrch  as  I  am  determent  to  have  it  done.    If  you  want 

to  know  anything  more  go  to  Mrs.  S 

Yours  sencerely 

Frank  C . 


These  letters  caused  no  little  consternation,  and  on  the  advice 
of  the  family  doctor  the  parents  brought  the  youth  to  see  me. 
I  found  him  a  small,  but  well-nourished,  ruddy-faced  young  man 
of  twenty-four  years,  somewhat  ungainly  in  body  balance  and 
walk,  but  presenting  no  marked  stigmata  of  degeneracy.  He 
talked  freely  and  pleasantly;  his  memory,  attention,  and  capacity 
for  observation  were  average ;  but  his  reasoning  was  very  poor,  and 
his  ideas  and  mode  of  expression  were  decidedly  childish.  It  was 
obvious  that  although  he  knew  how  to  do  certain  routine  farm  jobs, 
such  as  looking  after  the  cows  and  horses,  attending  to  the  fowls, 
digging  up  potatoes,  etc.,  he  had  no  idea  of  managing  a  farm  or  of 
looking  after  his  affairs.  During  our  conversation  he  said  that  he 
was  not  very  particular  about  getting  married  just  yet,  but  he  was 
rather  fond  of  Fanny.  When  I  asked  him  how  he  could  support 
her,  he  said  he  thought  he  would  get  a  job  like  her  father,  who  was 
his  father's  coachman.  On  my  pointing  out  that  even  if  he  suc- 
ceeded in  doing  this  it  would  still  be  some  time  before  he  could 


Illustrative  Cases  i8r 

keep  a  wife,  he  readily  agreed,  and  at  my  suggestion  said  he  would 
write  to  the  girl's  parents  and  clergyman  saying  he  had  decided 
not  to  marry  yet.  I  found  that  every  attempt  had  been  made  to 
educate  him  up  to  his  social  position  as  a  country  gentleman;  but 
he  was  quite  incapable  of  this,  and  infinitely  preferred  living  and 
working  with  the  farm  labourers  on  his  father's  estate.  At  my 
suggestion  he  was  sent  to  a  farm  run  by  a  medical  man,  where  he 
now  remains  quite  happy  and  contented. 

Lizzie  S is  the  first  and  only  child  of  a  respectable  couple 

who  are  lodge-keepers  on  a  large  country  estate.  I  can  find  nothing 
whatever  in  the  family  or  previous  personal  history  of  a  causal 
nature ;  but  it  must  be  admitted  that  the  parents  are  able  to  give 
very  few  details  of  their  relatives.  The  mother  says  that  Lizzie 
seemed  different  to  other  people's  children  when  she  was  seven 
months  old.  Whilst  other  children  "  would  be  wriggling  about, 
trying  to  get  down  and  want  a  lot  of  looking  after,  Lizzie  was 
always  so  quiet  and  so  good,  never  anything  seemed  to  put  her  out, 
and  she  had  no  temper  at  all."  She  cut  her  teeth  about  the  usual 
time,  but  was  very  late  in  standing  and  walking,  and  did  not  talk 
until  she  was  three  years  old.  Up  to  the  age  of  six  years  the  mother 
thought  she  would  grow  out  of  it,  but  when  she  went  to  school  she 
never  seemed  able  to  learn  at  all,  and  serious  doubts  began  to  enter 
the  mother's  mind  as  to  her  intellect.  The  schoolmistress  would 
not  keep  her  at  school,  and  she  remained  at  home  with  her  parents. 
She  was  always  quiet,  obedient,  and  well-behaved,  but  at  the  age  of 
•eighteen  she  evinced  a  fondness  for  young  men,  and  as  her  mother 
felt  that  they  could  do  anything  they  liked  with  her,  she  sought 
advice  as  to  her  condition. 

On  examination  at  the  age  of  eighteen  years,  I  found  her  to  be  a 
pleasant-faced,  smiling  girl,  somewhat  shy  and  hesitating  in  manner 
and  feeble  in  expression.  Her  physical  development  corresponded 
to  that  of  a  girl  of  about  fifteen,  and  signs  of  puberty  had  just 
appeared.  She  sat  quietly  in  the  chair,  attended  to  all  I  said  to 
her,  and  was  not  distracted  by  passing  events.  Her  cranial  cir- 
cumference was  20  inches.  She  knew  her  name  and  age,  and  when 
her  birthday  was.  She  said  London  was  a  "  big  town,"  but  did  not 
know  how  much  bigger  it  was  than  the  village  she  came  from,  but 
"  perhaps  it  is  twice  as  big."  She  said  the  sun  was  up  in  the  sky, 
not  very  far  away,  not  so  far  as  her  home,  it  would  not  take  her  long 
to  get  there  if  she  could  fly.     If  anyone  came  and  said  they  would 


1 82  Feeble-Mindedness  in  Adults 

take  her  a  trip  to  the  sun  in  a  flying  machine  she  would  go  with 
them.  She  would  go  with  one  now,  and  said  she  would  be  back  in 
time  for  dinner.  I  showed  her  a  model  of  a  cow.  She  looked  at  it 
and  said  it  was  a  lamb ;  but  on  being  told  to  look  again,  said  "  Cow." 
Upon  asking  her  what  cows  were  for,  she  said,  "  To  milk."  Upon 
being  asked  what  milk  was  for,  she  said,  "  Drinking,"  and  on  my 
asking  her  what  else,  after  a  very  long  pause  she  said  "  Cooking." 
I  asked  her  suddenly:  "  What  do  you  clean  your  boots  with  ?"  and 
she  at  once  replied:  "  Blacking."  She  said  she  went  to  church 
where  they  teach  her  "  hymns,  psalms,  and  about  Jesus."  But  she 
could  not  tell  me  a  single  fact  about  Jesus,  and  was  not  sure  whether 
He  is  dead  or  alive.  She  said  she  could  wash  clothes.  She  washed 
them  in  water.  I  asked  her  what  else.  She  said:  "  The  bath." 
She  could  not  tell  me  what  else  she  would  put  in  the  water. 
"  Nothing  else — plain  water."  \\Tien  I  suggested  soap  to  her  she 
smiled  and  said:  "Yes."  "What  kind  of  soap?"  "Sunlight," 
promptly.  I  asked  her  to  describe  a  fork  to  me.  After  much 
hesitation  she  at  length  said:  "  It's  steel,"  and  this  was  all  I  could 
get  out  of  her.  She  knew  the  names  and  uses  of  most  common 
objects,  but  could  tell  me  no  points  of  difference  between  paper  and 
cloth.  She  answered  the  first  nine  of  the  Binet-Simon  problem 
questions,  but  was  unable  to  answer  those  following.  She  said 
that  4-1-3=6;  2  +  3=4;  5  +  ^'  ^o  answer.  She  did  not  know  how 
many  pennies  there  were  in  a  shilling,  but  after  much  pressing  and 
hesitation  said  that  there  are  two  shillings  in  a  two-shilling  piece, 
and  she  took  forty-five  seconds  before  she  could  tell  me  that  there 
were  five  shillings  in  a  five-shilling  piece.  Her  mother  said  that 
Lizzie  could  peel  the  potatoes,  and  could  do  a  little  plain  knitting 
and  sewing,  but  could  not  put  a  garment  together ;  she  could  clean 
the  grate  and  lay  the  fire,  but  this  was  about  all,  and  even  in  doing 
these  the  mother  felt  that  she  must  always  keep  her  eye  on  her. 
If  sent  shopping  she  had  no  idea  of  change,  and  generally  forgot  to 
bring  some  of  the  things. 

I  regard  this  case  as  on  the  borderland  of  imbecility  and  feeble- 
mindedness. The  girl  has  observation  and  attention,  and  can  do 
many  little  things  she  has  been  taught  to  do.  She  has  no  school 
knowledge,  and  cannot  read,  write,  or  sum,  and  it  is  obvious  that 
her  association  and  ideation  are  poor  and  her  judgment  very  faulty. 
But  it  is  to  be  remembered  that  she  has  had  practically  no  training, 
and  I  think  it  highly  probable  that  had  this  been  supplied  she  would 


Illustrative  Cases  183 

have  made  a  most  useful  worker  in  a  laundry  or  some  similar  occu- 
pation. She  is  obviously  a  case  needing  permanent  supervision, 
and  without  this  her  facile  disposition  will  inevitably  lead  her  into 
trouble. 

I  am  acquainted  with  a  feeble-minded  man,  John  C ,  who  has 

steadily  and  industriously  cracked  stones  by  the  roadside  for  the 
past  forty  years.  He  lodges  in  the  village  with  a  labourer  and  his 
wife,  and  the  latter  wakes  him  in  the  morning,  gives  him  his  break- 
fast, makes  his  dinner  into  a  parcel,  and  sends  him  off  to  work. 
When  dinner-time  comes,  which  he  knows  by  seeing  the  labourers 
in  the  field  leave  off  work,  he  eats  the  contents  of  his  parcel.  Some- 
times John  feels  hungry,  and  eats  it  before.  About  five  o'clock, 
which  he  also  knows  by  the  passing  of  the  postman,  he  leaves  off 
work  and  returns  to  his  lodging.  He  has  his  tea,  sits  by  the  fireside 
until  about  eight,  and  then  goes  to  bed.  Occasionally  John  has 
been  known  to  get  tired  of  work  and  come  home  in  the  middle  of  the 
afternoon;  but  such  lapses  are  very  rare,  and  on  the  whole  he  is 
exceedingly  methodical  and  industrious.  He  knows  that  Sunday 
is  a  day  of  rest,  but  he  must  be  told  that  it  ie  Sunday,  or  he  would 
go  to  work  as  usual.  John's  landlord  once  played  him  the  prank 
of  not  telling  him  it  was  the  Sabbath,  and  he  went  off  as  usual 
without  any  suspicion.  But  he  had  intelligence  enough  to  notice 
the  trick  on  passing  through  the  village,  by  seeing  that  the  shop 
was  closed,  and  he  came  back  vastly  amused  at  what  he  thought 
was  a  fine  mistake.  He  receives  a  few  shillings  each  week  from  the 
Rural  District  Council,  and  this  he  faithfully  carries  to  his  landlady, 
who  allows  him  a  penny  now  and  then  when  he  asks  for  it.  This, 
however,  appears  to  be  seldom,  for  John  seems  to  be  in  the  happy 
condition  of  having  all  his  wants  supplied. 

One  might  describe  many  cases  similar  to  these,  both  in  town 
and  country;  but  it  is  unnecessary.  They  illustrate  very  well  the 
stable  type  of  feeble  mind,  and  the  manner  in  which  routine  work 
may  be  performed  by  this  class  with  comparatively  little  super- 
vision. I  have  even  known  several  who  have  served  their  time  in 
the  army.  It  is  necessary  to  remember,  however,  that  their  intelli- 
gence is  limited,  and  that  these  persons  must  not  be  entrusted  with 
work  beyond  their  capacity,  or  the  result  may  be  disastrous.  I 
may  mention  a  striking  example  of  this  which  occurred  in  the  case 
of  a  feeble-minded  woman  resident  in  a  workhouse.  Her  daily 
occupation  was  washing  in  the  laundry,  which  she  did  very  well. 


184  Feeble-Mindedness  in  Adults 

But  one  day  the  charge-nurse  of  the  maternity  ward  most  unfortu- 
nately gave  her  a  baby  to  wash.  She  did  so  in  boihng  water,  with, 
it  need  hardly  be  said,  a  fatal  result. 

But  although  these  persons  are  capable  of  useful  employ- 
ment, they  have  no  capacity  to  lay  out  the  money  they  earn  or 
to  manage  their  affairs.  Food,  clothing,  and  shelter  must  be 
provided  for  them,  just  as  with  children,  and  in  the  absence  of 
someone  to  look  after  them  they  soon  get  into  a  most  woeful 
plight. 

As  an  instance  of  their  general  "  incapacity  to  manage  their 
affairs  with  ordinary  prudence,"  I  may  mention  the  case  of  a  woman 
I  met  in  a  small  viUage  in  Somerset.  She  was  the  daughter  of  the 
village  shopkeeper,  and  upon  her  parents'  death  had  inherited 
sufficient  cottage  property  to  keep  her  in  comfort  for  the  rest  of  her 
life.  Unfortunately,  however,  no  one  was  appointed  to  look  after 
her,  and  so  it  came  about  that  little  by  little  she  was  diddled,  by 
relatives  and  acquaintances,  out  of  every  penny  she  possessed,  and 
when  I  saw  her  she  had  been  taken  in  out  of  pity  by  the  wife  of  a 
labouring  man,  who  received  a  few  shillings  weekly  from  the  parish 
to  look  after  her. 

Throughout  the  country  there  are  hundreds  of  feeble-minded 
persons,  many  of  them  gentlefolk  by  birth,  in  like  case.  As  long 
as  they  are  provided  with  a  home,  and  have  parents  or  relations 
to  generally  supervise  them,  things  go  well.  They  perform  little 
household  and  outdoor  duties,  take  up  simple  hobbies  like  poker- 
work,  stamp-collecting,  and  amateur  cabinet-making,  and  enter 
into  the  ordinary  social  amusements  of  the  class  to  which  they 
belong.  Most  of  their  friends  recognize  that  they  are  not  quite 
"  all  there,"  but  they  often  pass  muster  with  casual  acquaintances. 
But  once  let  them  get  away  from  the  parental  apron-strings,  and 
assume  the  responsibilities  of  an  independent  existence,  and  their 
want  of  mental  capacity  is  fully  revealed,  and  results  in  their  com- 
plete undoing.  In  the  case  of  feeble-minded  girls  this  general 
inability  to  take  care  of  themselves  is  particularly  evident,  and 
demonstrates  in  the  most  forcible  manner  the  urgency  of  the  need 
for  their  protection. 

Lastly,  it  may  be  said  that,  although  the  religious  and  moral 
sense  of  these  persons  is  rarely  of  a  high  order,  most  of  tliem  are 
conscious  of  the  difference  between  right  and  wrong,  and  of  the 
fact  that  the}'  have  certain  obligations  towards  their  neighbours. 


Plate  V. 


To  face  page  134.] 


,.■*(»■ 


Mentally  Unstable  Type  185 

A  certain  number,  indeed,  are  quite  capable  of  understanding  simple 
theological  doctrine. 

Feeble-minded  of  Unstable  Mental  Equilibrium. — It  is  not,  per- 
haps, surprising  that  the  mind  which  is  defective  should  also  lack 
balance,  and  in  a  very  considerable  number  of  feeble-minded  per- 
sons— indeed,  I  think  in  the  majority — the  mental  defect  is  accom- 
panied by  more  or  less  mental  instability.  This  may  not  become 
evident  until  the  physiological  epochs  of  puberty  or  adolescence 
have  been  reached,  and  one  meets  many  cases  in  which  the  whole 
disposition  of  the  individual  seems  to  undergo  an  alteration  at  these 
times;  but  often  the  condition  can  be  detected  in  childhood,  and  is 
shown  by  the  fits  of  irritability,  excitement,  moroseness,  sulkiness, 
or  so-called  "  bad  temper,"  which  are  present  in  a  considerable 
nmnber  of  defective  children. 

The  degree  of  instability  varies  much  in  different  individuals, 
and  at  different  times  in  the  same  individual.  Some  are  simply 
giggling,  emotional,  and  knpulsive,  liable  to  sudden  fits  of  way- 
wardness, but  readily  controllable,  and  on  the  whole  capable  of 
doing  useful  work.  I  have  known  one  of  this  type,  a  silly,  giggling, 
weak-minded  girl,  to  plunge  her  head  into  a  pail  of  water  without 
the  slightest  hesitation  when  the  suggestion  was  made  to  her. 
I  have  known  another  to  set  fire  to  a  hay-rick,  and  another  to  dash 
her  hand  violently  through  a  window-pane  in  a  sudden  access  of 
temper.  And  yet  all  of  them,  on  the  whole,  were  good,  willing 
workers  and  in  -fairly  constant  employment  (see  Plate  V.).  I  have 
seen  girls  of  this  type  who  have  caused  no  little  commotion  by 
"  faking  "  a  burglary,  even  going  to  the  length  of  gagging  and 
binding  themselves  and  giving  a  most  detailed  description  of  an 
imaginary  desperado. 

In  others,  however,  the  instability  is  more  persistent,  and  the 
person  is  so  changeable  and  undependable  that  continuous  em- 
ployment is  out  of  the  question  unless  the  closest  supervision  can 
be  maintained.  The  attacks  of  these  persons  often  have  much  of 
the  character  of  an  epileptic  seizure,  the  manifestations  being  mental 
rather  than  motor,  however. 

The  following  are  illustrative  cases  of  this  unstable  type  of  feeble- 
mindedness : 

Alice  S is  a  feeble-minded  girl  of  nineteen  years.     She  is  the 

daughter  of  working  people,  and  went  to  the  Board-school  until  she 
was  fourteen  years  of  age;  but  her  schoolmistress  says  she  could 


1 86  Feeble-Mindedness  in  Adults 

make  nothing  out  of  her,  that  when  she  left  she  could  only  just  read 
and  write,  and  that  she  was  "  always  spiteful,  untrustworthy,  and 
a  regular  nuisance."  Upon  leaving  school  a  situation  as  day-girl 
was  found  for  her.  She  ran  away  on  the  third  day,  and  refused  to 
go  back.  Then  she  got  another  place,  but  only  stayed  a  week,  as 
her  mistress  "  could  not  put  up  with  her  ways."  This  went  on  for 
over  two  years,  during  which  time  she  had  no  fewer  than  twenty- 
two  situations.  She  was  then  sent  to  a  laundry  training-home,  and 
here  for  the  first  few  weeks  she  was  much  quieter,  and  it  was  hoped 
that  she  would  settle  down  into  good  habits.  But  the  hope  was 
futile.  The  matron  found  that  not  the  slightest  dependence  could 
be  placed  upon  her  word,  that  she  was  dirty  in  her  person,  lazy,  an 
incurable  pilferer,  and  up  to  the  most  cunning  tricks  to  annoy  and 
irritate  her  companions.  She  was  therefore  sent  home  again.  Here 
she  remained  for  some  months,  doing  no  work,  and  causing  her 
relations  endless  trouble  and  worry.  On  several  occasions  she 
was  brought  home  by  the  police,  and  finally,  within  a  year  of  her 
return  from  the  training-home,  she  was  admitted  into  the  maternity 
ward  of  the  workhouse.  It  was  there  that  I  first  saw  her,  and 
although  she  was  a  strong,  active  girl,  and  quite  capable  of  doing 
domestic  work,  she  was  nevertheless  so  erratic,  impulsive,  and 
generally  irresponsible,  that  nothing  could  be  made  of  her. 

F.  H.,  .a  feeble-minded  man  twenty-three  years  of  age,  having 
the  appearance  of  a  youth  of  seventeen  or  eighteen.  He  is  5  feet 
in  height,  and  weighs  7 J  stones,  is  thin  and  ill-nourished,  and  has 
numerous  stigmata.  He  is  extremely  unstable,  at  times  being 
quiet  and  well-behaved,  at  others  noisy,  restless,  talking  and  laugh- 
ing to  himself,  and  interfering  with  those  around  him.  In  one  of 
these  fits  he  attacked  his  brother  with  a  hammer.  He  has  had 
several  situations,  but  has  been  unable  to  keep  any  of  them.  He  can 
read,  write,  and  do  simple  sums,  and  although,  when  questioned, 
he  seems  to  have  a  fair  knowledge  of  many  common  things,  he  is 
too  defective  and  unstable  to  turn  his  knowledge  to  any  account. 
He  is  a  ready  talker  when  in  the  mood,  and  gives  a  very  plausible 
account  of  himself.  He  says  he  is  "  what  you  call  an  orphan,  and 
only  has  his  brothers  to  be  acquainted  with  now.  Was  in  the  sixth 
standard  when  he  left  school,  and  used  to  do  reading,  writing,  arith- 
metic, composition,  and  geometry;  was  never  at  the  top  of  the  class 
— master  used  to  think  him  a  backward  boy.  It  was  writing  from 
memory  that  was  his  worst  subject;  memory  was  always  bad.     Once 


Mentally  Unstable  Type  187 

got  a  prize  for  religious  catechism.  Was  in  the  boys'  home  learning 
printing  for  nine  months,  but  they  gave  him  the  sack  because  he 
accidentally  spoilt  a  special  job.  Has  had  other  chances,  but  never 
seemed  to  get  on  very  well.  If  they  would  only  give  him  another 
chance  he  would  do  his  very  best.  Several  of  the  other  people  have 
interfered  with  him,  and  then,  of  course,  he  has  to  take  care  of 
himself.  One  of  his  masters  told  him  he  would  get  on  better  if 
he  didn't  allow  himself  to  be  put  on,  and  looked  after  himself 
more." 

Lastly,  in  another  group  of  these  unstable  feeble-minded  a  con- 
dition of  actual  insanity  is  present ;  but  as  this  is  a  complication  of 
some  importance,  I  shall  deal  with  it  in  a  subsequent  chapter. 

As  already  remarked,  it  is  likely  that  a  good  deal  of  the  mental 
instability  of  these  persons  is  the  result  of  an  unsuitable  environment 
in  early  life,  and  it  is  probable  that  careful  and  firm  training  during 
childhood  might  do  much  to  prevent  it.  I  am  certain,  however, 
that  it  is  often  inborn,  just  as  is  that  instability  of  mental  constitu- 
tion in  the  "  normally  "  developed  which  is  so  often  the  precursor 
of  insanity;  indeed,  I  am^  inclined  to  look  upon  all  feeble-minded 
persons  of  this  type  as  potential  lunatics. 

It  is  easy  to  understand  that  criminal  actions  may  be  committed 
by  such  persons,  and  there  is  no' doubt  that  they  constitute  the 
great  majority  of  feeble-minded  criminals.  Also,  although  prob- 
ably not  so  often  the  case  to-day,  there  is  little  doubt  that  in  years 
gone  by  those'  of  the  facile  type  were  frequently  made  use  of  to 
further  the  schemes  of  the  professional  law-breaker.  It  is  not 
merely  that  these  persons  are  incapable  of  appreciating  the  conse- 
quences of  their  actions — for  that  might  be  said  of  most  of  the 
feeble-minded — it  is  rather  that  their  defect  is  accompanied  by  such 
a  general  instability  of  mind  that  they  are  either  peculiarly  sus- 
ceptible to  any  suggestion,  or  are  liable  to  flare  up  for  the  most 
trivial  cause.  The  train  is  already  laid;  it  is  only  the  spark  that  is 
needed.  It  is  obvious  that  feeble-minded  persons  of  this  type  are 
much  more  likely  to  come  into  contact  with  the  authorities  than  are 
the  harmless,  placid  individuals  previously  described;  and,  as  a 
matter  of  fact,  a  very  large  number  of  them  are  inmates  of  our 
workhouses,  prisons,  asylums,  or  charitable  homes.  Still,  the  num- 
ber at  large  throughout  the  country  is  not  inconsiderable,  as  is 
shown  by  the  investigations  of  the  Royal  Commission. 

To  this  account  of  the  chief  characteristics  of  high-grade  amentia 


i88  Feeble-Mindedness  in  Adults 

we  may  add  that,  although  deficiency  of  some  kind  or  other  is  always 
present  in  the  highest  mental  faculties,  the  nature  of  this  is  subject 
to  considerable  variation.  In  many  persons  there  is  an  utter 
inability  to  acquire  any  kind  of  book-learning,  although  they  may 
use  their  hands  with  considerable  dexterity.  On  the  other  hand, 
there  are  those  who  possess  a  remarkable  aptitude  for  acquiring 
certain  forms  of  knowledge,  but  who  are  so  simple  and  childish  as 
to  be  utterly  incapable  of  providing  for  their  daily  wants.  Others, 
again,  as  will  be  seen  in  treating  of  moral  defectives,  have  a  degree 
of  cunning  and  intellectual  quickness  of  a  certain  order  which  is  at 
times  astonishing;  whilst  yet  others  are  stolid,  indifferent,  and 
entirely  negative.  It  is  thus  seen  that  mental  defect  cannot  be 
looked  upon  as  simply  a  lower  grade  of  the  normal,  but  as  a  dis- 
tinctly pathological  condition  in  which  defective  is  accompanied 
by  irregular  development.  Considered  from  the  standpoint  of 
practical  daily  life,  the  essential  characteristic  of  this  class  is  that, 
whereas  the  ordinary  person,  whether  quick  or  duU  witted,  profits 
by  his  experience,  and  learns  bit  by  bit  to  take  care  of  himself  and 
to  adapt  his  behaviour  to  the  exigencies  of  the  moment,  the  feeble- 
minded person  does  not.  The  defective  and  irregular  development 
of  his  mind  have  combined  to  bring  about  a  lack  of  that  quality 
which  is  so  hard  to  define,  and  yet  so  essential  to  success  in  life — 
common  sense.  In  any  doubtful  case,  therefore,  the  diagnosis  must 
rest  not  only  upon  the  examination  as  to  the  present  mental  attain- 
ments, but  also  upon  a  careful  consideration  of  the  previous  history 
and  general  conduct  of  the  individual,  as  will  be  more  fully  dealt  with 
in  a  later  chapter. 


CHAPTER    X 
IMBECILITY 

Definition. — The  term  "  imbecility  "  (Latin  imbecillus,  doubtfully 
derived  from  prefix  im  or  in,  and  bacillus,  a  staff — one  without  a 
stay  or  support,  hence  feeble,  helpless)  is  applied  to  the  medium 
grade  of  amentia ;  and  although  there  are  many  members  at  the  top 
and  bottom  of  this  grade  whose  condition  closely  approximates  to 
the  feeble-minded  and  the  idiots  respectively,  nevertheless  it  is  one 
which,  as  a  whole,  has  tolerably  well-defined  features.  The  im- 
beciles stand  above  the  idiots  in  the  possession  of  an  instinct  and 
partial  capacity  for  self-preservation,  but  below  the  feeble-minded 
in  their  inability  to  perform  sufficient  work  to  contribute  appreciably 
towards  their  support.  The  definition  suggested  by  the  Royal 
College  of  Physicians  and  adopted  in  a  former  edition  of  this  book 
was:  "  Those  persons  who,  by  reason  of  mental  defect  existing  from 
birth  or  from  an  early  age,  are  incapable  of  earning  their  own  living, 
but  are  capable  of  guarding  themselves  against  common  physical 
dangers."  The  recognized  legal  definition  now,  however,  as  given 
in  the  Mental  Deficiency  Act  of  1913,  is:  "Persons  in  whose  case 
there  exists  from  birth  or  from  an  early  age  mental  defectiveness  not 
amounting  to  idiocy,  yet  so  pronounced  that  they  are  incapable  of 
managing  themselves  or  their  affairs,  or,  in  the  case  of  children,  of 
being  taught  to  do  so." 

I  must  confess  that  I  do  not  think  this  is  an  improvement  upon 
the  previous  definition,  and  it  seems  to  me  to  be  just  as  applicable 
to  the  feeble-minded  as  to  the  imbecile  grade  of  amentia.  How- 
ever, it  is  the  one  now  recognized  by  the  Law  of  England,  and  which 
must  therefore  be  used  in  classifying  for  legal  purposes.  But  for 
scientific  and  descriptive  purposes  the  former  is  preferable. 

Number. — The  inquiries  of  the  Royal  Commission  of  1904  showed 
that  the  total  number  of  imbeciles  existing  in  England  and  Wales 


190  Imbecility 

on  January  i,  1906,  was  approximately  25,096  persons,  correspond- 
ing to  073  per  1,000  of  the  population.  The  class  is  thus  nearly 
half  as  numerous  as  the  adult  feeble-minded,  and  about  three  times 
as  numerous  as  the  idiots.  The  same  inquiries  show  that  imbeciles, 
both  absolutely  and  relatively,  are  more  prevalent  in  rural  than  in 
urban  and  industrial  areas. 

Sex. — There  is  a  slight  preponderance  of  the  male  sex,  and  out  of 
1,807  imbeciles  discovered  by  the  Royal  Commission  959  were  males 
and  848  females. 

Description. 

All  imbeciles  come  within  the  terms  of  the  first  definition  just 
given,  in  that  they  possess  the  instinct  of  self-preservation  as  well 
as  sufficient  appreciation  of  their  surroundings  to  avoid  the  common 
physical  dangers  which  threaten  existence.  For  instance,  an  im- 
becile realizes  that  the  fire  will  burn  him,  that  he  may  be  drowned 
if  he  falls  into  the  river,  or  killed  if  he  drops  from  a  height,  or  in 
front  of  a  railway  train,  and  he  has  sufficient  sense  to  get  out  of  the 
way  of  an  approaching  motor-car.  In  all  these  things  he  is  superior 
to  the  idiot.  On  the  other  hand,  he  is  lacking  in  the  ability  to 
perform  such  work  as  will  contribute  appreciably  towards  his  sup- 
port, although  he  may  carry  a  letter  or  parcel  and  do  simple  jobs 
under  supervision.  He  is  as  a  rule  incapable  of  reading,  although 
he  may  be  amused  with  pictures;  he  knows  practically  nothing  of 
arithmetic,  and  is  usually  unable  to  carry  on  a  rational  conversation. 
In  all  these  respects  he  is  inferior  to  the  feeble-minded.  But  whilst 
they  all  agree  in  these  common  characteristics,  a  certain  proportion 
present  such  marked  physiognomical,  and  often  mental,  peculiarities 
as  to  form  distinct  clinical  varieties.  These  varieties  will  be  de- 
scribed in  subsequent  chapters,  the  general  account  which  will  here 
be  given  of  imbeciles  and  idiots,  as  also  the  preceding  account  of 
the  feeble-minded,  referring  to  the  simple  type  (the  "  genetous  " 
group  of  Ireland),  to  which  the  great  majority  of  these  persons 
belong.     (See  Chapter  V.-,  Classification.) 

Physical  Condition. — In  a  small  number  of  perspns  suffering 
from  imbecility  of  the  secondary  form  (in  which  the  defect  is  acci- 
dental and  symptomatic  of  some  acquired  disease  of  the  brain), 
the  features,  stature,  and  general  bodily  development  may  not 
differ  from  those  of  a  healthy  person.  But  these  cases  are  not 
numerous,  and  in  the  great  majority  of  simple  imbeciles  of  the 


Plate  VI. 


To  face  page  190.^ 


Description  191 

primary  form  the  bodily  as  well  as  the  mental  condition  is  obviously 
defective. 

Occasionally  gigantism  is  seen,  but  as  a  rule  the  stature  is  several 
inches  less  than  that  of  the  normal  person.  In  addition,  the  body 
is  ill-formed,  its  balance  and  carriage  are  ungainly,  there  are  many 
oddities  of  walk  and  bearing,  whilst  stigmata  of  degeneracy  are 
both  numerous  and  prominent.  The  expression  of  the  imbecile 
is  usually  in  itself  sufficiently  striking  to  attract  attention,  varying 
from  a  stolid  vacuity  to  a  fatuous  and  childish  smile  or  a  look  of 
sly  cunning.  Disturbances  of  physiological  function  are  common. 
Various  degrees  of  paralysis  occur  in  a  certain  proportion  of  cases, 
and  probably  about  40  per  cent,  of  all  imbeciles  suffer  from  epilepsy. 
On  the  whole,  the  bodily  condition  is  so  distinctive  that  even  the 
casual  observer  has  little  difficulty  in  dubbing  one  of  this  class  a 
' '  daf  tie  "  or  "  natural. ' '     (See  Plates  VI . ,  VI I . ,  and  VI 1 1 . ) 

Mental  and  Nervous  Condition. — In  some  imbeciles  one  or  more 
senses  are  markedly  defective ;  in  others  there  is  an  increased,  and 
even  extraordinary,  delicacy  of  a  particular  sense;  in  the  majority, 
however,  sensory  perception  is  merely  obtuse,  and  a  condition 
similar  to,  but  decidedly  more  aggravated  than,  that  in  the  feeble- 
minded is  present.  The  tenacity  of  memory  for  isolated  events 
does  not  appear  to  be  diminished,  but  the  range  of  memory  is  de- 
cidedly inferior  to  that  of  the  normal  person.  Probably  this  is 
largely  the  result  of  a  defective  power  of  association.  Spontaneous 
attention  is  sometimes  diminished,  and  although  many  of  these 
persons  can  be  habituated  to  perform  routine  work  of  a  simple  kind, 
they  are  quite  incapable  of  any  task  necessitating  a  sustained 
effort  of  voluntary  attention.  A  few  of  the  milder  types  show 
some  evidence  of  imagination,  but  the  majority  are  lacking  in  this 
faculty.  Where  the  feeble-minded  person  will  invent  plausible 
excuses  to  escape  punishment  for  his  misdeeds,  the  imbecile  will 
simply  lie  without  embroidery.  Many  have  some  capacity  for 
imitation,  and  at  times  this  may  be  educated  sufficiently  to  enable 
them  to  perform  a  certain  amount  of  useful  work ;  but  they  readily 
tire,  and  in  most  cases  the  value  of  the  work  done  is  not  worth  the 
supervision  it  entails.  Occasionally  the  imbecile  is  markedly 
defective  in  volition,  but  this  is  by  no  means  always  the  case,  for 
some  of  these  persons  have  exceedingly  strong  desires,  and  are 
capable  of  no  little  strength  and  cunning  to  obtain  their  ends.  It 
is  often  easier  to  lead  than  to  drive  an  imbecile,  and  some  of  them 


192  Imbecility 

are  particularly  amenable  to  suggestion.  It  is,  however,  in  reason- 
ing capacity  that  the  most  marked  difference  is  seen  between  this 
class  and  the  feeble-minded.  The  latter  person,  although  very 
defective,  is  still  capable  of  simple  mental  comparisons,  and  of 
arriving  at  simple  judgments;  but  the  imbecile  is  usually  quite 
incapable  of  this. 

Abnormalities  of  movement  are  of  very  common  occurrence.  In 
the  apathetic  type  there  is  a  general  diminution,  whilst  in  those  of 
the  excitable  form  all  movement  tends  to  be  excessive.  These 
excitable  imbeciles  are  constantly  chattering,  running  about,  and 
generally  interfering  with  everybody  and  everything.  Some  of 
them  are  violently  aggressive,  and  a  few  become  actually  insane. 
Defects  of  co-ordination  are  both  commoner  and  more  pronounced 
than  in  the  feeble-minded.  Most  imbeciles  can  speak,  although 
they  can  only  form  simple  sentences,  and  their  vocabulary  is  a 
meagre  one.  The  development  of  the  faculty  of  speech  is  invariably 
late.  A  few  are  exceedingly  voluble  in  conversation,  but  the  matter 
is  childish  and  inconsequent.  Defects  of  pronunciation  are  numer- 
ous. Some  imbeciles  can  read  simple  sentences,  and  a  few  learn 
to  add  and  subtract  upon  their  fingers,  or  by  means  of  beads,  but 
the  scholastic  acquirements  of  the  class  as  a  whole  are  of  a  very 
low  order. 

Like  the  feeble-minded,  imbeciles  are  divisible  into  two  chief 
types — the  apathetic  or  stable  and  the  excitable  or  unstable.  Ac- 
cordingly, they  differ  greatly  in  their  disposition  and  general  beha- 
viour. Some  are  harmless,  inoffensive,  and  well-behaved;  but 
others  are  just  the  reverse,  and  require  to  be  under  constant  obser- 
vation. These  latter  are  often  sly  and  cunning  to  a  degree,  always 
in  trouble,  and  possessed  of  pronounced  immoral  and  anti-social 
tendencies.  Some  are  clean  in  habits,  modest,  and  possess  a  toler- 
able sense  of  decency ;  others  are  absolutely  destitute  of  any  idea  of 
shame  or  modesty.  Masturbation  is  very  frequent  in  imbeciles  of 
both  sexes,  and  many  of  them  will  practise  it  in  the  most  open  and 
outrageous  manner.  Some  imbeciles  show  unmistakable  signs  of 
jealousy,  and  a  considerable  number  are  exceedingly  vain,  not  only 
of  their  dress  and  general  appearance,  but  even  of  their  mental 
attainments. 

The  following  cases  illustrate  the  chief  features  of  simple  im- 
becility: 

C.  H.,  a  fat,  smiling  man,  forty  years  of  age,  who  has  been  in  the 


Plate  VII. 


"71 


■=-T3 


To  face  page  192.] 


Illustrative  Cases  193 

asylum  since  boyhood.  He  has  no  friends  living,  and,  beyond  a 
note  in  the  case-book  to  the  effect  that  there  is  insanity  on  the 
father's  side,  there  are  no  particulars.  He  understands  and  can 
carry  on  a  simple  conversation,  but  he  cannot  read  or  write,  and 
has  no  conception  of  figures.  He  can,  however,  appreciate  pictures, 
and  will  laugh  immoderately  at  anything  funny.  He  is  good- 
tempered  and  obedient,  but  a  perfect  glutton,  and  will  devour  any 
scraps  he  comes  across.  He  is  too  defective  to  be  entrusted  with 
any  work  without  supervision,  but  is  very  willing,  and  spends  most 
of  his  time  with  the  gardener  in  the  grounds. 

/.  F.,  male,  twenty  years  old,  is  the  last  born  of  a  family  of  seven, 
of  whom  three  died  in  early  childhood  (one  of  convulsions) ;  two 
are  said  by  the  mother  to  be  "  all  right,"  whilst  another  is  mentally 
defective.  The  father  is  alive,  but  has  been  insane  in  an  asylum 
twice ;  one  of  his  brothers  died  in  an  asylum.  The  mother  is  alive, 
but  in  delicate  health.  Two  of  her  sisters  and  one  brother  died  of 
consumption. 

James  has  always  been  "  delicate  " ;  he  did  not  stand  until  turned 
two  years,  and  did  not  walk  until  his  fourth  year.  He  was  over 
five  before  he  spoke,  and  even  now  his  vocabulary  is  limited  to 
about  a  dozen  words.  These  he  uses  very  sparingly,  and  it  is  rarely 
that  he  can  be  got  to  reply  to  questions,  although  he  understands 
a  good  deal  of  what  is  said  to  him.  He  never  attended  school,  as 
the  headmistress  refused  to  have  him.  He  remained  at  home 
quite  unoccupied  until  fifteen  years  of  age,  when  he  became  unruly 
and  more  than  his  mother  could  manage.  Since  then  he  has  been 
in  the  asylum. 

He  is  a  short,  stumpy,  fat  youth,  with  coarse  features,  large  out- 
standing ears,  and  a  typical  imbecile  expression.  He  has  a  high 
saddle-shaped  palate  and  very  irregular  and  malformed  teeth;  but 
these  cannot  always  be  demonstrated,  as  he  usually  obstinately 
refuses  to  open  his  mouth.  Cranial  circumference,  22-|  inches. 
There  is  no  paresis,  but  he  is  clumsy  and  heavy  in  all  his  movements. 
There  is  no  marked  defect  of  the  special  senses,  but,  owing  to  his 
usually  taking  not  the  slightest  notice  of  any  question  addressed 
to  him,  he  has  been  thought  to  be  deaf.  This,  however,  is  not  the 
case,  as  I  have  succeeded  in  getting  him  to  turn  round  at  the  sound 
of  a  whistle,  and  have  once  or  twice  managed  to  get  him  to  execute 
a  simple  command.  He  seems  to  have  little  idea  or  care  as  to 
where  he  is,  is  apparently  unconscious  of  the  flight  of  time,  and  is, 

13 


194  Imbecility 

as  a  rule,  perfectly  stolid  and  inoffensive.  But  occasionally  he  has 
a  noisy  outbreak,  and  then  he  will  rush  about  the  ward  grunting, 
yelling  and  interfering  with  anyone  whom  he  meets.  I  saw  him  one 
day  munching  biscuits  out  of  a  paper  bag  which  had  been  brought 
him  by  his  mother.  I  intercepted  each  biscuit  on  its  way  from  the 
bag  to  his  mouth.  He  did  not  seem  to  mind,  and  placidly  got 
another  out  of  the  bag.  When  I  had  succeeded  in  getting  them 
all,  he  stood  still  in  a  vacant,  perplexed  sort  of  way,  without 
seeming  to  understand  or  care  very  much,  and  after  a  time  he  walked 
away. 

H.  C,  female,  seventeen  years;  is  the  fourth  of  a  family  of  eight, 
three  of  whom  died  in  infancy;  insanitj'  and  epilepsy  on  father's 
side.  No  others  are  mentally  affected,  but  mother  says  they  are 
all  delicate.  The  patient  never  seemed  the  same  as  the  other 
children  from  birth,  and  did  not  walk  until  her  fourth  year.  She 
has  never  talked  properly.  She  went  to  school  for  several  years, 
but  never  learned  anything,  and  finally  the  mistress  said  she  had 
better  not  come  any  more,  so  she  has  since  been  at  home.  She 
understands  a  good  deal  of  what  is  said  to  her,  and  can  execute 
simple  commands,  such  as  to  shut  the  door  or  fetch  a  chair.  She 
can  answer  simple  questions  in  monosyllables,  but  her  articulation 
is  so  defective  as  to  be  unintelligible  to  a  stranger.  She  has  no  idea 
of  number,  and  everything  is  "  two."  She  has  no  knowledge  of 
letters,  but  can  make  strokes  and  ciphers  on  a  slate.  She  also 
knows  the  names  of  the  common  objects  of  the  house.  On  the 
whole,  she  is  quiet,  obedient,  and  good-tempered.  She  is  not 
actively  destructive,  but  wiU  always  pick  a  patch  off  her  clothes  if 
they  have  been  mended,  and  her  chief  joy  is  to  have  a  piece  of  cloth 
given  her  to  fray  out.  She  cannot  wash  or  dress  herself,  but  can 
feed  with  a  spoon,  and  is  of  clean  habits.  Her  chief  peculiarity 
seems  to  be  that,  as  soon  as  she  takes  the  first  mouthful  of  food, 
she  invariably  goes  to  sleep,  and  has  to  be  wakened  to  finish  her 
meal. 


Plate  VIII. 


3    > 


To  /(ICC  page  194. 


CHAPTER  XI 
IDIOCY 

Definition. — In  the  idiots  we  see  the  third  and  lowest  degree  of 
defect,  and  the  mental  deprivation  in  these  persons  is  indeed  such 
as  to  fully  justify  the  term  idios  (a  person  "  private,"  "  apart,"  or 
"  solitary  ")  which  is  applied  to  them. 

The  line  between  this  class  and  the  imbeciles  has  been  variously 
drawn  by  different  writers.  Some  would  consider  the  presence  or 
absence  of  speech  as  the  criterion,  but  there  are  many  imbeciles — 
and  even  feeble-minded — who  cannot  speak.  Others,  again,  would 
use  attention  or  volition,  but  these  are  not  necessarily  lacking  in 
the  idiot.  If  a  line  is  to  be  drawn,  and,  if  only  for  purposes  of 
description,  it  is  clearly  a  great  advantage  that  we  should  have  some 
means  of  differentiation,  then  I  think  that  the  absence  of  the 
instinct  or  power  of  self-preservation  constitutes  the  most  convenient 
one,  and  this  we  shall  accordingly  use. 

The  idiot  is  therefore  defined  a.s  "  a  person  so  deeply  defective  in 
mind  from  birth,  or  from  an  early  age,  as  to  he  unable  to  gtiard  himself 
against  common  physical  dangers."  This,  it  may  be  added,  is 
now  the  legal  definition  as  given  in  the  Mental  Deficiency  Act  of 

1913- 

Accepting  this  as  the  criterion,  it  is  at  once  seen  that  idiots  are 
divisible  into  two  groups.  In  one  of  these  the  defect  is  so  profound 
as  to  involve  the  fundamental  organic  instincts,  and  even  that  of 
sucking  is  absent.  These  are  termed  complete,  absolute,  or  prof  ound 
idiots.  In  the  second  group  the  primitive  instincts  are  present — 
there  is  even  some  glimmering  of  mind — but  there  is  not  sufficient 
intelligence  to  understand  and  avoid  the  common  physical  dangers 
which  threaten  existence.  These  may  be  termed  the  partial  or 
incomplete  idiots. 

Number. — The  number  of  idiots  existing  in  England  and  Wales 

195 


196  Idiocy 

on  January  i,  1906,  was,  approximately,  8,654  persons,  correspond- 
ing to  0-25  per  thousand  of  the  entire  population.  The  class  is  thus 
about  one-third  as  numerous  as  the  imbeciles,  and  comprises  about 
6  per  cent,  of  all  aments.  As  we  have  already  seen,  idiots  are  abso- 
lutely and  relatively  much  more  numerous  in  rural  than  in  urban 
districts,  and,  taking  areas  with  a  similar  incidence  of  total  amentia, 
we  find  that  there  are  often  from  four  to  five  times  as  many  idiots 
present  in  the  former  as  in  the  latter  situation.  A  similar  variation 
of  incidence  with  regard  to  environment  has  been  shown  to  obtain 
with  the  imbeciles  also,  but  the  disproportion  is  much  greater  in  the 
case  of  the  idiots. 

With  regard  to  sex,  the  inquiries  of  the  Royal  Commission  show 
that,  of  585  idiots  existing  in  the  16  areas  of  the  United  Kingdom 
which  were  investigated,  there  were  303  males,  and  282  females. 


Description. 

Partial  or  Incomplete  Idiocy — Physical  Condition. — The  various 
anatomical  and  physiological  anomalies  present  in  the  imbeciles, 
and  to  a  somewhat  less  extent  in  the  feeble-minded,  reach  their 
maximum  in  the  idiots;  and  the  members  of  this  degree  conse- 
quently present  an  appearance  which  is  in  itself  distinctive.  Some 
of  them  are  grotesque,  but  the  majority  are  such  stunted,  misshapen, 
hideous,  and  bestial  specimens  of  morbid  mankind  that  they  arouse 
feelings  of  horror  and  repulsion  rather  than  of  levity.  (See  Plates 
IX.  and  X.)  Paresis  or  paralysis  is  very  often  present,  and  this 
tends  still  further  to  aggravate  their  defective  physical  condition. 
In  some  cases  this  paralysis  is  due  to  a  non-development  of  the  tracts 
of  the  cord;  but  in  the  majority  it  is  the  result  of  disease  or  severe 
gross  lesions  of  the  brain  or  nervous  system  superadded  to  the 
original  developmental  defect,  such  as  porencephaly,  hydrocephaly, 
microgyria,  localized  atrophies,  and  anomalies  of  the  internal  ganglia. 
The  paralysis  may  be  slight  or  severe.  It  may  involve  a  hand  or 
foot,  or  be  a  complete  hemiplegia  or  diplegia.  Many  of  these 
creatures  are  in  consequence  chair-  or  bed-ridden.  Occasionally  the 
condition  known  as  "  scissor-legs  "  is  seen,  in  which  there  is  paralysis 
of  both  lower  limbs,  with  dislocation  of  the  hip-joints,  so  that  the 
legs  are  permanently  crossed  like  a  pair  of  scissors.  There  was  a 
very  perfect  example  of  this  at  Darenth  Asylum  a  few  years  ago. 
The  feature  of  most  of  these  paralyses  is  that  they  are  the  result  of 


Plate  IX. 


To  face  page  196.] 


Partial  or  Incomplete  Idiocy  197 

lesions  occurring  before  or  shortly  after  birth;  consequently  the 
limb  involved  is  stunted  in  its  growth  and  development. 

Epilepsy  is  very  frequent  in  simple  idiots,  and  occurs  in  about 
56  per  cent,  of  cases;  various  forms  of  tremor  and  athetosis  are  also 
frequently  seen. 

Many  idiots  are  extraordinarily  voracious,  and  gulp  down  their 
food  with  such  haste  as  to  be  in  imminent  danger  of  choking.  It 
has  more  than  once  happened,  where  spoon  diet  has  not  been  given, 
that  tracheotomy  has  had  to  be  performed  for  the  removal  of  a 
lump  of  food  from  the  lar\'nx.  In  a  few  cases  rumination  is  seen. 
Troublesome  diarrhoea  is  a  very  common  result  of  the  gluttony  of 
these  persons.  Ireland  mentions  two  cases  in  which  inordinate 
thirst  was  present,  the  patients  drinking  almost  any  kind  of  liquid 
in  enormous  quantities ;  neither  was  diabetic. 

Most  idiots  are  sterile,  but  this  is  not  always  the  case,  and  in 
some  sexual  feelings  are  obtrusively  evident.  As  a  class  they  are 
unusually  prone  to  disease  and  to  early  death,  particularly  from 
tuberculosis. 

Mental  and  Nervous  Condition. — Defects  of  sensation  are  very 
common  in  idiots,  and  although  morbid  conditions  of  the  end-organs 
of  special  sense  are  very  frequent,  nevertheless  the  lack  of  percep- 
tion seems  to  be  more  often  due  to  a  central  than  to  a  peripheral 
defect.  All  the  senses  may  be  affected,  but  it  usually  happens  that 
one  is  most  so.  We  thus  find  some  idiots  particularly  impervious  to 
sounds,  others  to  sights,  tastes,  or  odours. 

It  is  difficult  to  test  the  memory  of  these  persons,  but  on  the 
whole  I  am  inclined  to  think  that  it  is  usually  in  default.  Imagina- 
tion seems  to  be  wanting  altogether,  but  some  of  the  milder  types 
have  a  certain  capacity  for  imitating  the  actions  of  those  around 
them.  Active  attention  is  very  deficient,  but  spontaneous  attention 
is  by  no  means  always  absent.  Such  thoughts  as  exist  must  be  of 
the  simplest  description,  and  limited  to  objects  immediately  present 
to  their  senses.  They  have  no  power  of  reasoning,  and  although 
a  few  can  connect  simple  words  with  the  objects  to  which  they 
relate,  the  majority  cannot  do  this.  Idiots  have  to  be  washed, 
dressed,  and  fed  like  little  children;  many  of  them  are  utterlv  in- 
attentive to  the  calls  of  nature,  but  some  can  be  taught  habits  of 
regularity  and  cleanliness  in  this  respect.  They  are  by  no  means 
lacking  in  energy  and  volition,  and  many  of  them  apparently  ex- 
perience satisfaction  in  destroying  anything  they  can  get  hold  of; 


198  Idiocy 

l5ut  their  energy  cannot  be  directed  into  any  useful  channel,  nor  are 
they  even  capable  of  intelligent  play. 

Tears  are  very  rarely  seen,  but  there  is  no  doubt  that  some  of 
milder  degree  are  capable  of  the  simpler  emotions.  They  evince 
anger,  passion,  and  fright,  and  some  of  them  will  run  away  with  a 
look  of  alarm  upon  the  entrance  of  a  stranger.  They  seem  to  be 
absolutely  lacking  in  any  sense  of  right  or  wrong,  and  these  ideas 
cannot  be  implanted  in  them. 

Speech  is  usually  absent,  although  a  few  learn  to  articulate  such 
simple  monosyllables  as  man,  cat,  eat,  etc.,  but  none  of  them  can 
form  sentences.  Their  utterances  mostly  consist  of  inarticulate 
grunts,  screeches,  and  discordant  yells;  but  there  can  be  no  doubt 
that  these  often  express  their  feelings,  just  as  do  the  cries  of  animals, 
and  an  observant  physician  or  attendant  is  able  by  this  means  to 
discern  whether  they  are  satisfied  or  dissatisfied,  contented  or 
annoyed,  sometimes  even  to  interpret  their  simple  wants.  It 
is  noteworthy  that,  although  quite  unable  to  articulate,  some 
idiots  will  hum  a  tune  which  they  have  heard,  with  tolerable 
accuracy. 

Movement  is  often  abnormal  in  quantity  and  quality.  In  the 
apathetic  type  of  idiots  it  is  deficient;  in  the  excitable,  excessive. 
In  both  these  forms  co-ordination  is  usually  very  imperfect,  and 
they  are  hardly  ever  capable  of  any  dehcacy  of  manipulation.  In 
standing,  walking,  or  running  the  same  defect  of  co-ordination  is 
seen. 

Apathetic  and  Excitable  Idiots. — We  have  seen  that  the  less- 
pronounced  grades  of  defect  are  divisible  into  two  classes  according 
as  they  are  of  stable  or  unstable  mental  equilibrium ;  the  same  is  true 
of  the  idiots,  some  of  these  being  apathetic,  and  others  excitable. 
The  former  are  mild,  placid,  inoffensive  creatures  who  give  little 
trouble,  and  who  even  evince  a  certain  amount  of  affection  for  those 
who  feed  and  attend  to  them.  The  excitable  type,  on  the  other 
hand,  are  passionate,  violent,  untrustworthy,  and  intractable. 
Many  of  them  are  so  exceedingly  destructive  that  nothing  is  safe 
within  their  reach.  They  will  destroy  clothes,  toys,  picture-books, 
even  furniture,  and  if  left  alone  for  a  few  hours,  the  probability  is 
that  they  will  either  wreck  the  room  or  set  fire  to  or  seriously  injure 
themselves  in  some  way.  I  have  seen  several  of  this  class  in  cottages 
where  the  only  available  means  of  curtailing  their  activities  within 
a  reasonable  sphere  of  influence  was  to  tether  them  to  the  table  leg. 


Plate  X. 


To  face  page  iqS. 


Apathetic  and  Excitable  Idiots  199 

Often  they  are  exceedingly  cruel  to  animals,  and  seem  to  experience 
pleasure  at  the  cries  of  their  unfortunate  victims. 

Those  of  this  type  who  are  chair-ridden  still  manage  to  find  an 
outlet  for  their  excitability  in  the  almost  ceaseless  performance  of 
automatic  actions.  Thus,  some  will  spend  the  day  turning  the  head 
from  side  to  side  or  nodding  up  and  down ;  others  rock  the  body  to 
and  fro,  or  beat  upon  the  chest  with  the  hand,  often  keeping  time 
to  the  movement  with  a  monotonous,  inarticulate  chant;  others 
unceasingly  suck  their  fingers.  These  movements  do  not  occur 
during  sleep,  and  they  are  terminated  by  the  advent  of  feeding- 
time  or  the  entry  of  a  stranger,  although  at  times  a  visitor  seems  to 
stimulate  them  into  still  more  violent  activity.  It  is  evident  that 
they  are  attended  with  satisfaction,  for  the  patients  commonly 
resent  forcible  interruption,  and  resume  the  movements  again  the 
moment  they  are  free.  In  a  proportion  of  cases  this  condition  of 
restless  activity  is  not  constant,  but  intermittent,  and  resembles 
the  periodical  outbreaks  of  maniacal  excitement  which  occur  in  the 
milder  aments.  Such  persons  will  rush  about  the  room  or  dormitory 
uttering  hideous  screeches  and  yells.  In  moments  of  passion  they 
will  even  hurl  themselves  violently  against  walls  or  floor,  and  in  so 
doing  often  sustain  serious  injuries.  But  the  process  seems  to  be 
rather  pleasurable  than  painful.  Even  in  those  of  the  apathetic 
type,  the  advent  of  puberty  often  ushers  in  a  marked  alteration  of 
character  and  behaviour,  and  there  are  many  idiots  who,  having 
been  fairly  manageable  and  inoffensive  until  this  time,  then  become 
so  destructive  and  unreliable  that  the  restraint  of  an  institution  has 
to  be  sought. 

The  following  are  illustrative  cases: 

E.  J.,  female,  aged  thirty-two  years.  A  pronounced  history  of 
insanity  and  epilepsy  on  the  maternal,  and  alcoholism  on  the 
paternal,  side.  Has  been  in  the  asylum  since  seven  years  of  age. 
A  repulsive-looking  woman,  with  a  muddy,  freckled  face,  coarse  red 
hair,  and  numerous  stigmata;  cranial  circumference,  21  inches. 
She  can  walk,  but  spends  the  day  sitting  in  a  chair  turning  her  head 
from  side  to  side,  rocking  herself  to  and  fro,  and  biting  her  hands. 
She  is  of  unclean  habits  and  is  unable  to  do  anything  for  herself. 
She  is  quite  deaf  in  the  right  ear,  but  listens  attentively  to  the 
ticking  of  a  watch  held  close  to  her  left  one.  She  seems  to  have  no 
knowledge  of  time  or  place,  and  apparently  no  understanding  of 
anything  said  to  her.     But  when  the  piano  is  played,  she  at  once 


200  Idiocy 

ceases  her  rhythmic  movements  and  listens  attentively.  She 
cannot  speak,  but  she  will  hum  the  tunes  she  has  heard  so  well  that 
they  are  readily  recognized.  As  a  rule  she  is  harmless,  but  upon  any 
attempt  at  examination  she  makes  violent  resistance  and  tries  to 
bite,  and  she  is  at  times  spiteful  and  interferes  with  the  other 
patients. 

A.  D.  P.,  female.  Has  been  in  the  institution  since  childhood, 
but  the  family  history  is  not  obtainable,  as  there  are  no  friends 
living.  On  admission  she  was  unable  to  dress  or  feed  herself, 
and  had  no  apparent  understanding  of  anything  said  to  her.  She 
showed  no  curiosity,  no  imitativeness,  and  no  power  of  attention. 
Her  habits  were  unclean,  and  she  was  constantly  dribbling  from  her 
mouth.  She  was  a  voracious  eater.  She  was  unable  to  speak,  but 
addicted  to  violent  yells,  often  interspersed  with  a  peculiar  sound 
like  the  braying  of  a  donkey.  She  was  at  times  exceedingly  violent, 
kicking,  biting,  and  scratching  the  nurses  and  other  patients  indis- 
criminately, and,  in  fact,  was  generally  a  source  of  endless  trouble 
to  the  whole  ward.  She  remained  in  practically  the  same  condition 
until  thirty-five  years  of  age,  when  she  had  an  epileptic  attack. 
From  this  time  until  her  death  she  was  subject  to  occasional  recur- 
rences of  the  fits,  and  she  died  at  the  age  of  thirty-six,  of  gangrene 
of  the  lung,  resulting  from  the  aspiration  of  a  small  portion  of  food. 
The  cranial  circumference  was  20  inches,  and  there  were  numerous 
stigmata  of  degeneracy. 

On  making  a  post-mortem  examination,  I  found  a  very  thick, 
dense  skull  with  an  absence  of  diploe.  The  brain  was  small, 
weighing  1,022  grammes,  but,  beyond  being  very  simply  convoluted, 
there  were  no  naked-eye  anomalies.  Microscopical  examination, 
however,  revealed  extensive  imperfections  of  the  cells  of  both  brain 
and  spinal  cord  like  those  already  described. 

Absolute,  Complete,  or  Profound  Idiocy. — In  this  condition  we 
see  humanity  reduced  to  its  lowest  possible  expression.  Although 
these  unfortunate  creatures  are,  indeed,  the  veritable  offspring  of 
Homo  sapiens,  the  depth  of  their  degeneration  is  such  that  existence 
— for  it  can  hardly  be  called  life — is  on  a  lower  plane  than  even  the 
beasts  of  the  field,  and  in  many  respects  may  almost  be  described 
as  vegetative.  They  come  into  the  world  without  even  the  heredi- 
tary instinct  of  sucking.  As  they  grow  up  they  have  to  be  fed,  and 
would  die  of  inanition  amid  abundance  of  food  were  it  not  put  into 


Complete  Idiocy  201 

their  mouths.  If  they  are  conscious  of  excessive  heat  or  cold,  they 
are  devoid  of  any  idea  of  the  remedy.  They  respire,  assimilate, 
and  excrete,  but  they  have  no  sexual  instinct,  and  cannot  reproduce 
their  degenerate  species.  They  may  be  capable  of  inarticulate 
cries,  but  they  cannot  speak.  They  possess  the  power  of  muscular 
movement,  but  locomotion  is  absent.  They  have  eyes,  but  they 
see  not ;  ears,  but  they  hear  not ;  they  have  no  intelligence  and  no 
consciousness  of  pleasure  or  pain ;  in  fact,  their  mental  state  is  one 
entire  negation.  The  short  existence  of  most  of  these  creatures  is 
spent  in  bed,  where  they  lie  huddled  up  in  an  ante-natal  posture. 
They  are  hideous,  repulsive  creatures  whom  Nature  permits  to 
enter,  but  not  to  linger,  in  the  world,  and  in  their  life  and  death  are 
revealed  the  culminating  and  final  manifestation  of  the  neuropathic 
diathesis. 


CHAPTER  XII 
THE  CLINICAL  VARIETIES  OF  PRIMARY  AMENTIA 

It  is  probable  that  nearly  90  per  cent,  of  all  aments  belong  to  the 
primary  group,  and  the  majority  of  these,  as  already  mentioned, 
present  no  special  distinguishing  features  beyond  the  anatomical, 
physiological,  and  psychological  anomalies  common  to  primary 
aments  in  general.  These,  which  may  be  termed  the  simple  variety, 
have  been  described  in  the  preceding  pages. 

A  small  proportion,  however,  present  such  special  characteristics 
as  to  form  distinct  clinical  types.  The  chief  of  these  are  the  Micro- 
cephalics and  Mongolians,  and  these  will  be  described  in  the  present 
chapter.  We  shall  also  briefly  refer  to  some  clinical  subvarieties 
which  are  the  result  of  superadded  morbid  complications. 

The  Grecian,  American-Indian,  Negroid,  and  other  ethnic  types 
which  have  been  described  by  some  authors  do  not  seem  to  me  to 
possess  sufficiently  distinguishing  features  to  merit  special  notice. 

MICROCEPHALIC  AMENTIA. 

By  the  term  ' '  microcephalic  ament  ' '  is  usually  meant  a  person 
whose  skull  is  less  than  17  inches  in  its  greatest  circumference.  But 
in  view  of  the  fact  that  other  persons,  with  a  greater  cranial  measure- 
ment than  this,  present  similar  mental  peculiarities  as  well  as  skull 
configuration,  I  am  disposed  to  think  that  the  criterion  should  be  one 
of  shape  rather  than  size.  Most  members  of  this  variety  belong  to 
the  more  pronounced  degrees  of  amentia,  and,  if  the  test  of  measure- 
ment be  the  one  adopted,  they  probabh^  do  not  comprise  more  than 
about  5  or  6  per  cent,  of  all  aments.  If,  however,  the  milder  cases 
be  included,  and  the  criterion  be  that  of  cranial  shape,  this  nimiber 
is  considerably  increased,  and  probabh-  reaches  10  or  12  per  cent. 
Many  of  these  latter  are  merely  feeble-minded. 

Causation. — The   condition   is   one   which   has   attracted   much 


Microcephalic  Amentia  203 

attention,  particularly  from  anatomists,  and  two  views  have  been 
put  forward  as  to  its  causation.  The  first  of  these  is  that  it  is  an 
atavistic  variation;  the  second,  that  it  is  a  pathological  condition 
due  to  premature  closure  of  the  cranial  sutures. 

One  of  the  earliest  advocates  of  the  atavistic  theory  was  Charles 
Vogt,  of  Geneva,  who,  in  a  paper  published  in  1867,*  attempted  to 
show  that  microcephaly  was  a  reversion  to  a  prehuman  type.  Many 
cases  were  examined,  and  most  minute  dissections  made  by  accom- 
plished anatomists  on  the  Continent  and  in  this  country.  Con- 
clusive evidence  was  adduced  in  support  of  the  view,  and  equally 
conclusive  facts  in  denial  of  it.  It  was  at  a  time  when  the  evolu- 
tionary theory  was  attracting  widespread  attention,  and  it  was  not 
lo  be  wondered  at  that  the  curious  appearance  of  microcephalics 
should  cause  them  to  be  looked  upon  as  instances  of  a  reversion  to 
a  simian  type.  It  is  unnecessary  to  enter  into  the  pros  and  cons 
•of  the  argument ;  it  is  sufficient  to  state  that  the  fact  has  now  been 
•established,  as  a  result  of  many  examinations,  that  microcephaly  is 
not  an  atavistic  variation,  but  a  pathological  condition,  and  that 
these  persons,  although  degenerate,  are  still  human. 

The  second  theory,  that  microcephaly  was  due  to  a  premature 
synostosis  of  the  cranium,  attracted  hardly  less  interest.  Bail- 
largerf  seems  to  have  been  the  author  of  this  view,  and  he  enunciated 
it  on  the  strength  of  some  apparently  very  definite  statements  by 
the  mothers  of  microcephalic  children,  that  at  birth  the  anterior 
fontanelle  was"  closed.  These  statements  were  corroborated  by 
Baillarger's  examination  of  some  cases  in  which  synostosis  was 
present.  But  it  has  since  been  found  that  many  microcephalics 
€xist  in  whom  the  sutures  are  not  closed ;  in  fact,  such  is  the  excep- 
tion rather  than  the  rule,  and  hence  this  theory  is  now  discarded. 
In  the  instances  in  which  bony  union  has  taken  place,  it  is  much 
more  likely  to  be  the  effect  than  the  cause  of  the  arrested  cerebral 
development. 

The  real  truth  is  that  microcephaly  is  neither  atavistic  nor 
accidental,  but  the  result  of  inherited  blight,  just  as  is  amentia  in 
general.  In  most  of  the  cases  which  I  have  examined  morbid 
inheritance  was  present ;  in  fact,  microcephalics  usually  come  of  a 

*  C.  Vogt,  Geneva,  "  Memoires  sur  les  Microcephales  ou  Hommes  Singes," 
1867.  On  this  subject  see  also  "  I  Cervelli  dei  Microcefali,"  Professor 
Giacomini,  Turin,  1890;  also  an  excellent  chapter  in  Dr.  Ireland's  work. 

t  Baillarger,  Gazette  Midicale  de  Paris,  1857,  p.  482;  also  Cruveilhier. 
"  Anatomie  Pathologique  Generale,"  Paris,  1876. 


204     The  Clinical  Varieties  of  Primary  Amentia 

pronounced  neuropathic  stock,  their  brothers  and  sisters  are  often 
typical  degenerates,  and  frequently  one  or  more  of  them  suffer  from 
the  same  condition.  Houze*  has  described  a  family  in  which  twa 
children,  their  father  and  grandfather,  were  all  microcephalics. 
They  are  simply  the  result  of  a  more  gross  developmental  arrest 
than  that  which  obtains  in  the  majority  of  aments.  There  seems 
to  be  little  doubt  that  many  of  the  dwarfs  exhibited  in  public  have 
been  microcephalics;  on  the  other  hand,  such  dwarfs  as  Joseph 
Boruwlaski,  Zimmermann,  Jeffrey  Hudson,  and  Tom  Thumb  have 
shown  marked  intelligence  in  spite  of  their  small  cranial  capacity. 
The  explanation  of  this  is  doubtless,  as  mentioned  by  Dr.  Hastings 
Gilford, t  that  these  latter  are  examples  of  ateleiosis  in  which  the 
correlation  between  size  of  brain  and  of  body  remains  normal.  But 
it  is  important  to  bear  in  mind  that  microcephalic  amentia  is  due 
to  no  mere  disparity  in  the  relative  size  of  the  brain,  but  to  qualita- 
tive changes  in  the  brain  cells  in  addition. 

Pathology. — The  characteristic  of  this  condition  is  a  hypoplasia 
of  the  cerebral  hemispheres,  which  is  more  particularly  pronounced 
in  the  temporo-sphenoidal,  parietal,  and  occipital  regions,  so  that 
the  posterior  lobes  of  the  cerebrum  rarely  suffice  to  cover  the  cere- 
bellum. To  this  the  peculiar  "  sugar-loaf  "  conformation  of  the 
skull  is  due.  In  most  cases,  although  under-developed,  the  primary 
sulci  may  be  traced ;  but  in  some  instances  these  are  very  imperfect ; 
in  the  majority  of  cases  there  is  also  a  marked  deficiency  in  the 
secondary  gyri,  so  that  the  complexly  convoluted  aspect  of  the  nor- 
mal brain  is  entirely  wanting.  In  addition,  there  is  often  localized 
agenesis  of  particular  areas,  resulting  in  the  condition  described  as 
"  microgyria,"  as  well  as  gross  developmental  anomalies  of  the 
corpus  callosum  and  internal  ganglia.  Not  a  few  cases  are  com- 
plicated by  some  recent  morbid  process,  of  which  the  commonest 
are  porencephaly,  encephalitis,  and  hydrocephalus.  The  cerebellum 
is  smaller  than  the  normal,  but  is  not  affected  to  anything  like  the 
same  extent  as  the  cerebrum.  The  hypoplasia  nearly  always  in- 
volves the  spinal  cord,  which  is  much  thinner  and  shorter  than 
normal.  The  parts  most  affected  are  the  pyramidal  tracts  and 
columns  of  GoU,  the  anterior  columns  and  direct  cerebellar  tract 
somewhat  less  so.     Disseminated  sclerosis  and  pseudo-hypertrophic 

*  Houze,  "  A  Case  of  Hereditary  Microcephalus,"  Bull,  de  la  Soc.  d'Anthrop. 
de  Bruxelles,  tome  xxi. 

t  Hastings  Gilford,  "  Disorders  of  Post-Natal  Growth  and  Development," 
igii. 


Microcephalic  Amentia  205 

paralysis  have  also  been  noticed  in  microcephalics  (Langdon  Down). 
From  the  stage  of  development  of  the  cerebral  fissures,  it  is  quite 
evident  that  the  cause  is  one  which  has  been  at  work  before  birth. 
Microscopical  examination  of  these  cases  usually  reveals  a  similar 
condition  of  irregular  and  imperfect  development  of  the  cells  of  the 
brain  cortex  to  that  already  described.  The  anterior  horn  cells  of 
the  spinal  cord  also  frequently  show  similar  changes. 

The  weight  of  the  brain  varies  very  much  in  these  cases.  The 
lightest  on  record  is  the  one  described  by  Dr.  Sander,  as  mentioned 
by  Ireland,  which  only  weighed  170  grammes  (about  6  ounces).  A 
case  described  by  Dr.  Fletcher  Beach  weighed  198-4  grammes, 
whilst  the  brain  of  the  celebrated  Helene  Becker  weighed  219 
grammes.  But  these  are  somewhat  exceptional  examples,  and 
typical  microcephaly  may  be  present  with  a  brain  weighing  several 
hundred  grammes  more  than  these.  The  normal  weight,  it  may  be 
remembered,  varies  from  about  1,100  to  1,400  grammes  in  the  male 
(mean  average,  1,374  grammes  or  about  48  ounces),  and  1,000  to 
1,300  grammes  in  the  female  (mean  average,  1,244  grammes  or  about 
43  ounces). 

In  view  of  the  extreme  smallness  of  the  brain  in  these  persons, 
the  question  naturally  arises  as  to  the  influence  of  size  of  brain 
upon  intelligence.  There  is,  no  doubt,  a  brain  weight  and  cranial 
circumference  so  small  as  to  be  incompatible  with  anything  more 
than  a  state  of  idiocy,  and  Felix  Voisin  places  this  at  13  inches  cir- 
cumference. Excluding  dwarfs,  it  is  tolerably  certain  that  with  a 
cranial  circumference  of  17  inches  the  mental  capacity  will  not  range 
above  that  of  imbecility,  and  it  is  probable  that  the  adult  whose 
cranial  circumference  is  more  than  2  inches  less  than  the  normal 
minimum  will  be  feeble-minded.  But  beyond  this  we  cannot  go, 
and  even  these  statements  can  only  be  considered  as  of  general 
application,  for  the  size  of  the  brain  must  be  considered  in  relation 
to  the  size  of  the  body. 

The  average  size  of  the  skull  in  aments  is  decidedly  less  than  the 
mean  average  of  normal  persons,  although  there  are  a  few  (excluding 
hydrocephalics)  in  which  the  normal  measurements  are  exceeded. 
But  even  in  aments,  apart  from  extreme  cases  like  those  of  micro- 
cephaly, there  is  no  constant  relationship  between  the  amount  of 
intelligence  and  the  cranial  capacity. 

The  same  is  true  of  normal  persons.  The  range  of  variation  in  the 
mentally  sound  is  as  much  as  700  to  800  grammes  (about  26  ounces). 


2o6     The  Clinical  Varieties  of  Primary  Amentia 

and  there  have  been  even  eminent  men  who  have  diverged  from  the 
normal  to  a  greater  extent  than  this.  For  instance,  the  heaviest 
healthy  brain  on  record  is  that  of  Turgenieff,  the  Russian  novelist, 
which  weighed  71  ounces,  whilst  that  of  Gambetta  weighed  but 
40'9  ounces.  The  head  of  Shelley  was  also  very  small.  The  brain  of 
Napoleon  was  53  ounces,  that  of  Cuvier  58-3  ounces,  whilst  the  brains 
of  Abercrombie  and  Daniel  Webster  each  weighed  over  63  ounces. 
But  a  whole  race,  the  ancient  Peruvians,  attained  to  a  very  con- 
siderable degree  of  social  development  and  excellence  in  the  arts 
with  a  mean  average  brain  capacity  of  only  40-1  ounces.  Dr. 
Wilder*  has  recently  described  a  remarkably  light  brain  in  a  man 
who  died  at  the  age  of  forty-six  years.  He  was  5  feet  6  inches  in 
height,  and  weighed  145  pounds,  and  at  the  time  of  his  death  was 
employed  as  a  watchman.  He  could  read  and  write,  was  always 
regarded  as  being  in  the  full  possession  of  his  faculties,  and  had 
worked  as  a  labourer  in  one  situation  for  twenty  years.  From  all 
reports,  there  was  nothing  defective  or  peculiar  about  him,  either 
mentally  or  physically.  Upon  making  a  post-mortem  examination, 
no  measurements  of  the  skull  were  taken,  but  it  did  not  appear 
unusual  in  size  or  shape.  The  brain  filled  the  cranium,  there  being 
no  excess  of  liquid  or  evidence  of  compression,  but  its  weight  in 
the  fresh  state  was  only  24  ounces  (680  grammes) .  The  cerebellum 
seemed  nearly  normal  in  size  and  form,  whilst  the  cerebrum  was 
only  about  half  the  usual  weight,  and  peculiar  in  several  respects. 
As  against  this  may  be  mentioned  a  brain  described  by  Dr.  G.  A. 
Watsonj  which  is  probably  the  heaviest  on  record.  The  patient 
was  an  epileptic,  who  died  in  Rainhill  Asylum ;  but  before  the  epi- 
lepsy appeared  he  was  of  quite  average  intelligence,  with  consider- 
able musical  ability.  The  weight  of  the  brain  was  2,130  grammes 
(75  ounces) ;  it  was  of  good  general  shape,  and  remarkably  complex 
in  its  convolutions.  The  large  size  could  not  be  accounted  for  by 
any  pathological  appearances,  since  a  thorough  microscopical  exam- 
ination showed  a  normally  developed  cortex,  the  only  degenerative 
changes  present  being  those  commonly  seen  in  cases  of  long-standing 
epilepsy. 

The  fact  is  that  intellect  is  dependent  upon  quality  as  well  as 
quantity  of  brain,  and  although  in  many  aments  a  quantitative 
defect  is  present,  there  is  always  a  qualitative  deficiency  also. 

*   B.  G.  Wilder,  Journal  of  Nervous  and  Mental  Disease,  February,  1911. 
f   G.  A.  Watson,  Report  of^Lunacy  Commissioners,  1913. 


Plate  XI. 


To /ace  -iage  206. ) 


Microcephalic  Amentia  207 

Accordingly  it  results  that  even  in  microcephalics  there  is  no  con- 
stant relation  between  size  of  brain  and  mental  capacity. 

Description — Physical  Condition. — The  two  chief  clinical  dis- 
tinguishing features  of  this  variety  of  amentia  are  the  peculiar 
configuration  of  the  skull  and  the  (usually)  very  small  stature.  As 
a  result  of  the  cerebral  hypoplasia,  there  is  a  marked  deficiency  in 
the  frontal  and  occipital  regions  of  the  cranium,  which  in  conse- 
quence shelves  away  in  a  curiously  "  sugar-loaf  "  or  cone-like 
manner.  This  shape,  by  some  termed  oxycephalic,  is  always  present 
in  microcephaly,  and,  taken  in  conjunction  with  the  receding  chin, 
gives  a  very  characteristic  and  bird-like  appearance  to  these  crea- 
tures. (See  Plates  XL,  XVIIL,  and  XIX.)  In  consequence  of  the 
diminished  surface  of  bone  to  be  covered,  the  scalp  is  nearly  always 
extraordinary  thick  and  redundant.  In  some  cases  it  is  perma- 
nently thrown  into  a  series  of  deep  furrows  running  antero-pos- 
teriorly,  a  condition  which  was  first  described  in  this  country  by 
Dr.  T.  W.  McDowall,*  and  which  seems  to  be  confined  to  micro- 
cephales.|  In  addition  the  hair  is  usually  extraordinarily  coarse 
and  wiry,  and  on  more  than  one  occasion  I  have  known  the  teeth  of 
the  clipper  to  be  broken  whilst  the  hair  was  being  cut. 

As  already  remarked,  the  cranial  circumference  in  these  cases 
varies  very  much,  and  the  diagnostic  feature  is  one  of  shape  rather 
than  of  size.  There  have  been  several  cases  recorded  in  which  the 
greatest  circumference  was  15  inches  or  under;  on  the  other  hand, 
I  know  several  typical  microcephalics  with  a  cranial  circumference 
of  19  inches  and  more,  and  one  whose  skull  measures  as  much  as ' 
21  inches.  It  is  to  be  remembered  that  the  actual  brain  capacity 
is  less  than  a  mere  circumferential  measurement  would  suggest, 
by  reason  of  the  deficiency  being  chiefly  in  the  upper  parts  of  the 
skull. 

The  second  characteristic,  that  of  diminished  stature,  is  not  so 
constant;  nevertheless,  as  a  class,  microcephalics  are  the  smallest 
of  the  varieties  of  amentia,  and  many  of  them  may  be  called  dwarfs. 

*  T.  W.  McDowall,  "  Abnormal  Development  of  the  Scalp,"  Journal  of 
Mental  Science,  January,  1893;  also  a  further  account  by  T.  W.  and  C. 
McDowall,  Journal  of  Mental  Science,  July,  1912. 

t  Dr.  McDowall  was  good  enough  to  place  a  portion  of  the  scalp  of  one  of 
these  patients,  who  died  under  his  care,  at  my  disposal  for  examination. 
I  found  a  considerable  thickening  of  all  layers,  the  average  thickness  down  to 
the  roots  of  the  hair  foUicles  being  from  4  to  5  miUimetres,  and  this  after 
hardening  in  spirit. 


20 8     The  Clinical  Varieties  of  Primary  Amentia 

Few  of  them  grow  to  more  than  5  feet,  although  "  Joe  "  (described 
by  Dr.  Ireland)  reached  5  feet  9  inches  in  his  boots.  But  this  is 
decidedly  exceptional. 

In  other  respects  microcephalics  present  the  anomalies  common 
to  aments  in  general,  and  which  have  already  been  described. 
They  rarely  live  to  an  advanced  age  (in  this  respect  also  I  think 
"  Joe  "  is  unique,  since  he  was  sixty  years  old  at  his  death),  and  the 
majority  die  of  tuberculosis. 

Mental  and  Nervous  Condition. — The  intellectual  capacity  of  these 
persons  varies  within  very  considerable  limits,  and  we  thus  have 
microcephalic  aments  of  each  of  the  three  degrees  of  deficiency.  A 
considerable  number  are  idiots,  unable  to  do  anything  for  them- 
selves, unable  to  understand  more  than  a  few  words,  and  incapable 
of  speech.  Others,  and  the  majority,  belong  to  the  imbecile  class, 
and  are  capable  of  understanding  most  of  what  is  said  to  them,  can 
say  a  few  words,  and  can  perform  simple  tasks.  A  few  are  merely 
feeble-minded.  The  case  of  "  Joe  "  is  probably  the  best  example 
of  the  mildest  degree  of  defect,  for  Dr.  Ireland  says  that  until  after 
forty  years  of  age  he  was  apparently  able  to  earn  sufficient  wages  to 
maintain  himself.  I  know  several  typical  microcephalics  amongst 
mentally  defective  children  attending  special  schools  who  can  read, 
write,  do  simple  sums,  and  who  probably  possess  sufficient  intelli- 
gence to  earn  their  living  under  supervision ;  and  one  woman  of  this 
type,  with  a  cranial  circumference  just  under  17  inches,  is  one  of  the 
most  industrious  inmates  of  a  county  asylum. 

The  mental  features  common  to  most  microcephalics  are  the 
absence  of  any  sensory  defect,  a  general  vivacity,  restlessness  and 
muscular  activity,  a  considerable  capacity  for  imitation,  and, 
usually,  an  inability  for  sustained  effort.  In  their  perceptive 
faculties  these  persons  often  compare  favourably  with  aments  of 
considerably  higher  general  intelligence,  and  many  of  them  not  only 
have  remarkably  good  hearing  and  sight,  but  extremely  quick 
powers  of  observation.  The  restlessness  is  sometimes  expressed  by 
the  performance  of  peculiar  actions  which  have  caused  them  to  be 
likened  to  various  animals.  Thus,  Lombroso  describes  a  "  bird 
man,"  a  "  rabbit  man,"  and  a  "  goose  man."  Their  power  of 
mimicry  is  often  very  marked,  and  this,  combined  with  their  general 
alertness,  causes  them  to  be  amongst  the  drollest  inmates  of  the 
imbecile  ward.  There  was  a  chattering,  restless  ament  of  this  type 
at  Darenth  a  few  years  ago,  who  was  very  pat  in  making  remarks 


Microcephalic  Amentia  209 

upon  anything  coming  under  his  observation,  and  who  was  a  source 
of  endless  amusement  to  the  attendants  by  his  witticisms  concerning 
one  of  them  in  particular.  Another  boy,  aged  eleven  years,  with  a 
cranial  circmnference  of  15!  inches,  was  most  adept  in  mimicking 
the  various  performers  in  the  band. 

In  disposition  the  majority  are  affectionate  and  well-behaved. 
Many  of  them,  before  training,  it  is  true,  are  apt  to  be  quarrelsome 
and  difficult  to  manage,  but  they  usually  soon  lose  these  propen- 
sities and  become  quite  amenable  to  the  discipline  of  an  institution. 

The  majority  of  microcephalics  of  the  idiot  degree  suffer  from  a 
condition  of  general  helplessness,  which  causes  them  to  be  unable 
to  do  anything  for  themselves,  and  many  of  the  imbecile  grade 
■even  experience  considerable  difficulty  and  unsteadiness  in  walking. 
This  does  not  appear  to  be  due  to  actual  paralysis  (although  I  have 
seen  a  few  cases  with  typical  spastic  paralysis  and  increased  tendon 
reflexes),  but  to  an  imperfect  development  of  the  tracts  of  the 
spinal  cord.     About  half  of  them  are  subject  to  epileptic  fits. 

In  conclusion  we  may  briefly  cite  the  chief  instances  of  this 
interesting  condition  which  have  been  recorded.* 

Dr.  Wilbur  described  (1857)  ^-^  ^^^^t  aged  twelve  years,  in  the 
^ew  York  State  Asylum,  whose  cranial  circumference  was  only 
T3^  inches.  He  was  passionate,  uncleanly  in  his  habits,  could  distin- 
guish a  variety  of  forms  and  colours,  knew  the  names  of  all  objects 
in  the  schoolroom  and  about  the  house,  and  recognized  a  great 
number  of  pictures  of  objects.  He  made  but  little  progress  in 
•speaking,  and  after  being  in  the  asylum  five  years,  though  improved 
in  many  respects,  he  was  found  incapable  of  further  progress,  and 
was  dismissed. 

Antonia  Grandoni  was  described  by  Professor  Filippo  Cardona,  of 
Milan  (1870).!  She  was  a  typical  microcephalic,  with  a  cranial 
•circumference  of  15  inches;  her  height  was  49^  inches;  and  she  died 
at  the  age  of  forty-one  years.  She  had  no  sensory  deficiency;  in 
fact,  her  hearing  was  very  quick  and  her  observation  very  keen. 
She  understood  what  was  said  to  her,  and  was  able  to  converse. 
She  had  a  good  memory  for  persons  and  events,  was  of  a  sociable 
and  decidedl}^  amorous  and  erotic  disposition,  and  much  addicted 
to  dancing.  Although  decidedly  defective,  she  had  sufficient  inteUi- 
gence  to  do  simple  domestic  duties  and  to  run  errands;  in  fact,  con- 

*  For  these  particulars  I  am  largely  indebted  to  Dr.  Ireland's  work. 
t  D'Una  Micvocefala,  Milano,  1870. 

14 


2IO     The  Clinical  Varieties  of  Primary  Amentia 

sideling  the  extremely  small  size  of  her  brain,  her  intelligence,  was 
altogether  remarkable. 

Helena  Becker  died  of  phthisis  at  the  age  of  eight  years,  and  a 
very  careful  and  complete  examination  was  made,  and  report 
pubhshed,  by  Dr.  Bischoff  of  Munich  (1873).*  This  girl  was  a 
low-grade  idiot;  she  knew  her  own  name,  but  was  practically  in- 
capable of  understanding  anything  beyond,  although  she  knew 
when  people  were  angry  with  her.  Her  speech  was  limited  to  one 
word.  She  was  very  restless,  always  moving  her  hands  and  arms 
and  the  upper  part  of  her  body.  The  brain  weighed  219  grammes. 
Another  child  in  the  family  was  microcephalic. 

The  "  bird  man,"  a  microcephalic  with  a  cranial  circumference  of 
15  inches,  was  described  by  Professor  Cesare  Lombroso  (1873). f 
He  was  so  named  from  a  habit  of  chirping  like  a  bird,  hiding  his 
head  under  his  armpit,  leaping  on  one  leg,  and  stretching  out  his 
arms  like  wings.  He  was  said  to  be  wanting  in  touch,  taste,  and 
smell,  was  dirty  in  his  habits,  and  given  to  coprophagy.  Pro- 
fessor Lombroso  also  recorded  two  other  microcephalics  under  the 
designation  of  the  "  rabbit  man"  and  the  "goose  man,"  also  the 
three  brothers,  Nicolo,  Serafino,  and  Giovanni  Cerretti.  These  were 
aged  twenty-one  years,  thirteen  years,  and  ten  years,  and  had  a 
skull  circumference  of  17!,  i6|,  and  16^  inches  respectively. 

The  "  Aztecs  "  were  a  pair  of  microcephalic  aments,  boy  and  girl,, 
of  American-Indian  origin,  who  were  exhibited  all  over  Europe  and 
America  for  forty  years,  and  who  have  been  described  at  various 
periods  by  different  writers,  including  Professor  Owen.  They  were 
seen  by  Dr.  Dalton  when  aged  seven  and  five  years  respectively, 
and  were  described  as  being  only  able  to  repeat  a  few  isolated  words, 
but  very  excitable,  vivacious,  in  almost  constant  motion,  and  full 
of  curiosity.  Their  habits  as  regards  feeding  and  taking  care  of 
themselves  were  those  of  children  two  or  three  years  old.  They 
were  publicly  married  in  London  in  1867,  but  had  no  offspring. 
They  were  alive  in  1893,  but  I  have  been  unable  to  find  any  record 
of  them  since  that  time. 

Freddy,  who  was  under  the  observation  of  Dr.  Shuttleworth  for 
twenty  years  at  the  Royal  Albert  As5^1um,  died  at  the  age  of  twenty- 
nine  years,  of  phthisis.  At  the  time  of  his  death  his  height  was 
4  feet  8  inches,  the  cranial  circumference  was  15  inches,  and  the 

*  Anatoniische  Beschreibung  eines  mikrocephalen,  8  Jahrigen  Miidchens. 
f  Rivista  Clinica  di  Bologna,  July  and  November,  1873. 


Mongolian  Amentia  (Mongolism)  211 

weight  of  the  fresh  brain  was  I2|  ounces.  The  cranial  circumfer- 
ence at  eight  years  was  14J  inches,  and  at  twelve  years  14J  inches. 
Dr.  Shuttleworth  describes  him  as  manifesting  good  powers  of 
observation,  but  only  able  to  express  himself  in  a  few  monosyllabic 
words.  He  had  considerable  will-power,  and  though  it  was  found 
impossible  to  train  him  to  much  that  was  useful,  he  was  in  no  sense 
a  low-grade  idiot.  A  very  complete  examination  of  this  case  was 
made  and  recorded  by  Professor  J.  D.  Cunningham  and  Dr.  T. 
Telford-Smith  (1895).* 

Joe,  who  was  examined  by  Dr.  Ireland  in  the  Lancaster  Work- 
house at  the  age  of  forty-five  years,  had  a  cranial  circumference  of 
17  inches,  and  attained  the  unusual  height  of  5  feet  9  inches  (in 
boots).  Until  eighteen  months  previously  he  had  earned  enough 
wages  to  keep  himself,  and  he  died  at  the  age  of  sixty  years,  of 
phthisis.  This  case  also  was  fully  described  by  Cunningham  and 
Telford- Smith. 

In  a  district  of  the  Punjab  is  a  shrine  to  which  are  brought  micro- 
cephalic imbeciles  from  all  parts  of  the  country  to  be  placed  under 
the  care  of  Shah  Daula,  the  incumbent  saint.  These  creatures  are 
named  Shah  Daula's  "  Rats,"  from  their  facial  resemblance  to  this 
rodent,  and  they  were  first  described  by  Ewens.  There  is  a  good 
deal  of  mystery  attaching  to  their  origin,  but  Ewens  suspects  that 
their  numbers  are  kept  up  by  practices  which  occur  at  the  shrine. 
They  have  recently  been  further  described  by  Couchoud.f 


MONGOLIAN  AMENTIA  (MONGOLISM). 

The  Mongolian,  Kalmuc,  or  Tartar  variety  of  amentia  was  first 
so  named  by  Dr.  J.  Langdon  Down,  from  the  facial  resemblance  of 
these  persons,  in  certain  particulars,  to  members  of  the  Mongolian 
race.  When  well  marked,  their  peculiar  characteristics  give  rise  to 
a  physiognomy  and  clinical  picture  which  is  exceedingly  distinctive 
and  unmistakable,  but  it  must  be  admitted  that  not  a  few  aments 
are  met  with  who  present  only  some  of  the  features  of  this  class, 
and  who  are  thus  intermediate  between  the  Mongolian  and  the 
simple  variety  of  amentia.     Such  are  often  called  "  semi-Mongols." 

*  Transactions  Royal  Dublin  Society,  vol.  v.,  Series  2,  Part  VIII.  An 
excellent  recent  account  of  microcephaly  is  that  by  Dr.  Giovanni  Mingazzini 
(Monatsschrift  ur  Psychiat.  und  Neurologie,  Band  vii.,  Heft  6,  June,  1900). 
This  gives  most  of  the  literature  to  date. 

t  P.  L.  Couchoud,  L'Encephale,  March  10,  1912. 


212     The  Clinical  Varieties  of  Primary  Amentia 

The  number  of  Mongols  is  not  large.  If  only  those  with  well- 
marked  characteristics  be  included,  they  probably  do  not  form  more 
than  about  4  or  5  per  cent,  of  all  aments.  One  often  hears  it  said  that 
they  are  on  the  increase,  but  I  know  of  no  data  in  support  of  this 
statement.  In  Germany,  according  to  Vogt,  they  are  much  less  fre- 
quent, and  only  occur  to  the  extent  of  i  per  cent,  of  all  aments. 
Many  of  the  physical  features  of  this  class  are  noticeable,  at  or 
shortly  after,  birth,  and  this  fact,  together  with  their  retardation 
of  development,  causes  them  to  be  not  infrequently  seen  in  the 
consulting-room  and  the  outpatient  department  of  hospitals  de- 
voted to  children.  They  bear  a  superficial  resemblance  to,  and  are 
often  confounded  with,  cretins;  in  fact,  this  type  of  amentia  used 
formerly  to  be  called  "  cretinoid  "  idiocy. 

Causation. — The  cause  of  this  condition  is  stiU  shrouded  in  ob- 
scurity, and  although  for  the  present  it  seems  better  placed  amongst 
the  varieties  of  primary  amentia,  it  is  in  some  respects  so  suggestive 
of  some  specific  glandular  or  nutritional  defect,  that  it  is  quite  prob- 
able that  it  may  eventually  have  to  be  removed  to  the  secondary 
group.  Dr.  G.  A.  Sutherland,*  in  one  of  the  best  accounts  we  have 
of  Mongolism  as  seen  in  the  early  years  of  life,  remarks  that  these 
children  "  resemble  each  other  so  closely  that  they  appear  to  be 
members  of  the  same  family,"  and  he  very  truly  argues  from  this 
that  the  cause  is  more  likely  to  be  particular  than  general,  such  as 
those  concerned  in  the  production  of  the  majoritj^  of  aments. 
"  General  causes,"  he  says,  "  such  as  parental  alcoholism,  nervous 
disease,  or  insanity  in  the  family,  etc.,  are  not  likely  to  produce 
such  an  exact  tj'pe  of  disease  as  exists  in  Mongolism.  It  seems 
probable  that  one  and  the  same  cause  is  at  work  in  all  cases." 
Sutherland  found  that,  out  of  his  total  of  twent\'-five  cases,  syphilis 
was  definitely  present  in  eleven  patients,  and  from  the  symptoms 
and  history  it  was  strongly  suspected  in  three  others.  He  therefore 
suggests  that,  whilst  further  investigation  is  required  to  ascertain 
the  exact  etiological  factor,  the  condition  may  turn  out  to  be  a 
parasyphilitic  one. 

It  is  undoubtedly  true  that  the  curious  assemblage  of  physical 
signs  which  are  present  in  typical  Mongolism  does  suggest  a  certain 
uniformity  of  causation  in  these  cases.  But  it  is  necessary  to 
remember  that  Mongolism  consists  in  a  particular  combination  of 

*  G.  A.  Sutherland,  "  ^Mongolian  Imbecility  in  Infants,"  based  on  a  study 

of  twenty-five  cases,  Practitioner,  December,  1S99. 


Mongolian  Amentia  (Mongolism)  213 

anomalies  rather  than  in  anomalies  which  are  distinctive  in  them- 
selves, and  there  are  many  ordinary  aments  who  possess  one  or  more 
of  the  features  which  go  to  make  up  the  tout  ensemble  of  the  Mongol ; 
in  fact,  I  do  not  know  of  any  single  feature  of  these  persons  (with 
the  possible  exception  of  the  tongue)  which  may  not  be  seen  in 
other  aments.  It  is,  therefore,  the  combination  only  which  is  dis- 
tinctive. With  regard  to  the  question  of  syphilis,  the  evidence 
produced  by  Dr.  Sutherland  is  undoubtedly  very  strong;  but,  as 
equally  strong  evidence  to  the  contrary,  it  may  be  stated  that,  in 
over  twenty  cases  of  this  variety  in  which  I  investigated  the 
family  history,  I  was  unable  to  discover  any  preponderance  of 
syphihs,  and  in  some  of  the  cases  I  have  no  hesitation  in  saying 
positively  that  sjrphilis  was  not  to  be  thought  of.  It  is  also  inter- 
esting to  note  that  of  eight  cases  subjected  by  Dr.  Gordon*  to  the 
^^^assermann  reaction,  not  one  gave  a  positive  result.  In  nearly 
all  my  cases  there  was  a  neuropathic  family  history,  and  frequently 
a  strong  tubercular  taint;  but  over  and  beyond  this  what  I  did 
frequently  find  (and  what  I  think  may  possibly  be  the  factor  common 
to  this  type)  was  a  history  pointing  to  a  condition  of  uterine  ex- 
haustion or  ill-health  of  the  mother  during  gestation.  Many  of  the 
patients  were  the  later  born  of  a  large  family,  often  numbering  as 
many  as  ten  or  twelve,  and  where  this  was  not  the  case  there  was 
usually  a  state  of  severe  physical  prostration  of  the  mother  during 
the  gestation  period,  j  It  is  possible  that  many  conditions,  syphilis 
included,  may  bring  this  about,  and  I  have  on  several  occasions  seen 
children  produced  by  weakly  mothers,  at  the  end  of  the  child- 
bearing  period,  who  had  quite  a  Mongolian  type  of  physiognomy, 
but  who  were  mentally  normal.  At  the  same  time  it  is  to  be  noted 
that  the  birth  of  a  Mongol  may  be  followed  by  that  of  other  children 
who  appear  to  be  perfectly  normal,  and  I  do  not  think  I  have  ever 
known  two  Mongols  born  in  the  same  family. 

I  am  disposed  to  think,  therefore,  that  Mongolian  amentia  is  the 

*  J.  L.  Gordon,  Lancet,  September  20,  191 3 

t  Dr.  Bodil  Hjorth,  of  Copenhagen,  in  a  paper  recently  published  on  the 
"Etiology  of  Mongolism,"  gives  particulars  regarding  the  antecedents  of 
twenty-one  cases.  "  The  observed  conditions  assumed  as  possible  causes  are 
phthisis  in  the  parents  or  grandparents,  neuropathic  heredity,  and  alcoholism. 
None  of  these  occur  so  often  as  to  show  a  preponderating  influence.  There 
is  no  record  of  syphilis  in  any  of  the  cases.  Twins  presenting  the  specific 
characters  are  noted,  these  children  being  the  eighth  and  ninth  of  a  family 
of  ten.  Out  of  the  twenty-one  cases,  twelve  were  the  last  children  in  the 
family  "  [Journal  of  Mental  Science,  January,  1907). 


214     The  Clinical  Varieties  of  Primary  Amentia 

result  of  the  two  factors,  morbid  heredity  and  uterine  exhaustion, 
or  some  specific  nutritional  defect,  and  that  with  a  pronounced 
degree  of  the  latter  the  morbid  inheritance  may  be  only  sHght.  In 
one  of  my  cases  there  was  no  neuropathic  heredity,  but  the  mother 
had  suffered  from  severe  albuminuria  and  anaemia  whilst  carrying 
the  child. 

Pathology. — The  brain  of  the  Mongol  is  usually  smaller  and  less 
complexly  convoluted  than  that  of  the  normal  person.  In  addition, 
there  is  a  diminution  in  the  size  of  the  pons,  medulla,  and  cere- 
bellum. This  is  not  a  noticeable  peculiarity  of  ordinary  aments, 
and  it  seems  to  be  a  constant  characteristic  of  this  class.  Dr.  A.  W. 
Wihnarth,*  as  a  result  of  the  examination  of  five  Mongols,  found 
that  the  brains  were  of  good  size  for  imbecile  brains,  but  that  the 
pons  and  medulla  were  very  small,  being  only  about  half  the  normal 
weight.  He  suggests  that  the  low  nutrition  of  these  patients  (and 
possibly  other  anatomical  peculiarities)  may  be  due  to  the  imperfect 
development  or  absence  of  certain  cell  groups  in  this  region. 

I  have  had  the  opportunity  of  examining  the  central  nervous 
system  of  a  male  MongoHan  who  died  aged  fourteen  days.  In  this 
the  weight  of  the  complete  encephalon  was  340  grammes,  which 
may  be  considered  as  normal.  The  weight  of  pons,  medulla,  and 
cerebellum  was  19  grammes,  the  relationship  between  these  struc- 
tures and  the  cerebrum  being  thus  i  to  i6-8.  According  to  Huschke, 
the  normal  relationship  between  these  and  the  cerebrum  is  as  7  to 
93  (roughly,  one-thirteenth)  at  birth.  The  relative  and  absolute 
weight  of  the  cerebellum  undergoes  a  considerable  increase  with 
age,  however,  and  in  the  adult  the  proportion  to  the  cerebrum  is 
as  13  to  87  (roughly,  one-seventh).  It  is  thus  seen  that  in  this 
case  there  is  a  definite  diminution  of  these  basal  structures.  No 
other  naked-eye  changes  were  observed.  Microscopical  examina- 
tion showed  an  immature  condition  of  the  cells  and  tracts  of  all 
portions  of  the  encephalon  and  spinal  cord;  but  the  degree  of  de- 
velopment did  not  appear  to  be  behind  that  of  a  normal  nervous 
system  of  similar  age.  The  brain  cells  of  the  normal  child  at  birth 
are  in  a  very  embryonic  condition,  however,  and  it  is  hardly  to  be 
expected  that  any  microscopical  differences  would  be  discoverable 
at  this  early  age. 

It  is  very  probable  that  the  imperfect  development  of  the  basal 

*  A.  W.  Wilmarth,  "  Report  on  the  Examination  of  One  Hundred  Brains 
of  Feeble-Minded  Children,"  Alienist  and  Neurologist,  October,  1S90. 


Plate  XII. 


To  face  p  age  2 1 4.  J 


Mongolian  Amentia  (Mongolism)  215 

parts  of  the  encephalon  results  in  a  deficient  expansion  of  the  base 
of  the  skull,  and  Sutherland  plausibly  suggests  that  this  may  be 
a  factor  in  causing  the  characteristic  physiognomy  of  these  persons. 

It  may  be  stated  that,  beyond  the  presence  of.  congenital  mal- 
formations common  to  all  aments,  dissections  have  hitherto  failed 
to  reveal  any  abnormality  of  glandular  or  other  bodily  structures 
which  would  account  for  the  peculiar  characteristics  of  this  class. 
The  amentia  is  in  all  probability  idiopathic  and  due  to  hereditary 
defects,  but  these  special  physical  characteristics  may  be  brought 
about  by  morbid  influences  or  malnutrition  acting  during  the 
period  of  intra-uterine  growth. 

Description — Physical  Condition. — The  three  anomalies  most 
constantly  present  in  Mongolism,  and  whose  combination  may  be 
said  to  be  characteristic  of  this  condition,  are  of  the  skull,  the  eyes, 
and  the  tongue.  These  are  often  so  pronounced  as  to  render  a 
diagnosis  possible  at,  or  very  shortly  after,  birth.  In  exceptional 
cases,  however,  only  two  may  exist.  In  addition,  there  are  many 
other  peculiarities  of  frequent  occurrence ;  but  these  are  less  distinc- 
tive of  Mongols,  many  of  them  being  by  no  means  rare  in  ordinary 
aments.  Several  illustrations  of  this  type  of  amentia  are  shown 
in  Plates  XII.,  XIII.,  and  XIV. 

The  skull  is  small,  rounded,  and  diminished  in  its  antero-posterior 
measurement  (brachycephalic),  the  face  arid  occiput  being  con- 
siderably flattened.  But  there  is  no  marked  recession  of  the  frontal 
and  supra-occipital  regions,  so  that,  although  Mongols  are  of  the 
small-headed  type  of  aments,  the  cranial  conformation  is  markedly 
different  to  the  microcephales  proper.  The  palpebral  fissures  are 
narrow  and  oblique,  sloping  downwards  and  inwards.  It  was  this 
peculiarity  which  caused  Langdon  Down  to  apply  the  name  "  Mon- 
gol "  to  the  type;  but  although  generally  present,  it  is  not  invariably 
so.  Dr.  C.  H.  Fennell,*  in  a  series  of  twenty-one  cases,  found  it 
absent  in  three,  whilst  in  one  the  direction  was  reversed.  It  was 
only  present  in  fourteen  of  the  twenty-eight  cases  described  by 
Drs.  Pearce,  Rankine,  and  Ormond.f  Moreover,  it  occurs  in  the 
mentally  sound,  and  I  know  several  remarkably  intelligent  persons 
possessing  this  peculiarity. 

*  C.  H.  Fennell,  "  Mongolian  Imbecility,"  Journal  of  Mental  Science, 
January,  1904.  An  excellent  account  of  Mongolism  as  seen  injinstitutions, 
based  upon  twenty-one  cases. 

f  Pearce,  Rankine,  and  Ormond,  "  Notes  on  Twenty-Eight  [Cases  of 
Mongolian  Imbeciles,"  British  Medical  Journal,  July  23,  1910. 


21 6     The  Clinical  Varieties  of  Primary  Amentia 

An  exceedingly  characteristic  feature  is  the  tongue,  which  is 
unusually  large,  marked  by  h5T)ertrophied  circumvallate  papillae, 
and  scored  by  a  series  of  irregular  transverse  fissures.  Fennel! 
regards  this  condition  as  pathognomonic,  and  says:  "  In  the  exam- 
ination of  the  tongue  in  over  200  idiots  of  all  other  tj^pes,  I  met 
with  none  which  at  all  recalled  it."  But  a  few  Mongols  of  mature 
age  do  not  present  this  peculiarity.  Some  very  interesting  details 
with  regard  to  the  tongue  have  been  recorded  by  Dr.  John  Thom- 
son,* of  Edinburgh.  He  finds  that,  although  the  organ  may  be 
noticeably  large  at  birth,  the  other  characteristics  of  fissuring, 
swollen  papillae,  and  sodden  rawness  do  not  develop  until  consider- 
ably later.  He  says  the  enlargement  of  the  papillae  most  commonly 
begins  between  the  third  and  ninth  months,  whilst  the  fissuring 
generally  begins  to  appear  in  the  course  of  the  third  or  fourth  year. 
It  may  be  present  in  a  slight  form,  however,  during  the  second,  and 
it  may  not  be  noticeable  till  as  late  as  the  sixth  year.  Dr.  Thomson 
suggests  that  these  changes  may  be  partly  due  to  an  abnormal 
vulnerability  of  the  mucous  membrane,  but  that  vv^hat  chiefly  deter- 
mines the  swelling  and  cracking  is  the  habit  of  sucking  the  tongue 
which  is  commonly  present  in  these  children.  I  am  of  opinion  that 
this  is  an  exceedingly  probable  explanation,  for  it  is  an  undoubted 
fact  that  a  very  marked  feature  of  Mongolism  is  the  tendency  to 
chronic  inflammatory  conditions  of  skin  and  mucous  membranes; 
whilst  Thomson  has  shown  that  the  exciting  factor — tongue-sucking 
— occurs  in  at  least  80  per  cent,  of  these  patients. 

In  addition  to  the  oblique  direction  of  the  palpebral  fissures, 
other  abnormalities  of  the  eyes  are  exceedingly  common.  Thus, 
ectropion  and  epicanthus  are  often  seen ;  strabismus  and  nystagmus 
are  frequent  in  the  first  few  months  of  life,  but  tend  to  disappear  as 
the  child  grows  up.  Speckled  irides  are  very  common,  a  condition 
to  which  my  attention  was  first  drawn  by  Dr.  R.  Langdon  Down,  who 
also  considers  that  hypermetropic  astigmatism  is  unusually  preva- 
lent. Dr.  A.  W.  Ormondf  has  pointed  out  the  extreme  frequency 
with  which  cataract  occurs  in  these  patients.  Out  of  a  series  of 
twenty-eight  cases,  nineteen  had  lens  opacities,  and  in  all  but  one 
the  cataract  was  of  a  particular  type.  In  the  slighter  degrees  it 
took  the  form  of  a  series  of  dots  in  the  cortical  portion  of  the  lens, 

*   John  Thomson,  "  Notes  on  the  Peculiarities  of  the  Tongue  in  Mongol- 
ism," British  Medical  Journal,  May  4,  1907. 
t  A.  W.  Ormond,  British  Medical  Journal,  November_i8,  191 1. 


Plate  XIII. 


To  /ace  page  216.] 


Mongolian  Amentia  (Mongolism)  217 

which  were  so  small  as  to  be  invisible  by  transmitted  light,  but  were 
readily  made  out  by  focal  illumination.  In  the  later  stages  these 
dots  increased,  and  produced  a  lamellar  cataract.  Dr.  Ormond 
failed  to  find  these  changes  in  patients  under  nine  years  of  age,  and 
looks  upon  them  as  being  of  a  progressive  nature.  I  think  it  is 
quite  likely  the  presence  of  these  cataracts  which  causes  the  curious 
habit  of  rolling  the  eyes  up  and  down  and  from  side  to  side  which 
some  of  these  patients  possess. 

The  ears  are  usually  small  and  rounded,  with  a  badly  developed 
lobule.  The  nose  is  short  and  squat,  with  triangular  nostrils,  which 
often  look  forwards  rather  than  downwards.  The  teeth  do  not  show 
any  special  features  beyond  the  ill -formation  and  proneness  to  decay 
which  are  common  to  aments  in  general.  The  hair  is  generally 
very  dry,  scanty,  and  wiry.  There  is  frequently  seen  a  bright  red 
flush  upon  the  cheeks  of  these  patients,  very  much  like  that  occur- 
ring in  myxoedema.  The  palate  is  often  high  and  narrow,  the  mouth 
open,  the  lips  transversely  fissured,  and  the  tongue  partly  pro- 
truding.    Adenoids  are  exceedingly  frequent. 

The  hands  and  feet  are  commonly  broad,  flabby,  and  exceedingly 
clumsy-looking.  Dr.  Telford- Smiith  described  a  curious  incurving 
of  the  little  fingers  as  very  characteristic  of  Mongolism,  but  in  my 
experience  it  is  not  much  commoner  in  this  t}^e  than  in  aments  in 
general.  What  I  have  frequently  found  is  that  both  the  little 
fingers  and  thumbs  are  much  shorter  than  normal,  and  that  whereas 
in  the  ordinary  person  or  ordinary  ament  the  tip  of  the  little  finger 
usually  ends  opposite  the  last  joint  of  the  ring-finger,  in  Mongols  it 
is  very  common  to  find  it  extend  no  farther  than  the  middle  of  the 
second  phalanx.  The  whole  hand  frequently  deviates  towards  the 
ulnar  side.  A  very  common  characteristic  is  an  unusually  large 
cleft  between  the  big  toe  and  the  next  one.  In  the  early  years  of 
life  there  is  usually  an  exceedingly  lax  condition  of  the  joint  liga- 
ments, and  this  gives  rise  to  a  greatly  increased  mobility,  so  that 
the  fingers  and  knees  can  be  hyperextended  to  a  considerable  degree. 
Knock-knee  and  flat-foot  are  common.  The  skin  is  rough  and  dry, 
and  often  covered  with  fine  hairs.  The  subcutaneous  tissues  fre- 
quently have  a  curious  boggy  feeling,  like  that  present  in  myx- 
oedema, but  there  is  no  pitting  on  pressure.  The  abdomen  is  usually 
large  and  tumid,  particularly  in  infancy,  and  umbilical  hernia  is 
occasionally  seen. 

In  many  of  these  persons  the  circulation  is  very  defective,  and 


21 8     The  Clinical  Varieties  of  Primary  Amentia 

blueness  and  coldness  of  the  extremities,  sores  and  chilblains,  are 
exceedingly  prevalent.  This  may  probably  be  due  to  congenital 
cardiac  anomalies,  such  as  imperfect  closure  of  the  foramen  ovale, 
pulmonary  stenosis,  etc. ;  but  in  some  instances  it  may  be  the  result 
of  intra-uterine  endocarditis.  Dr.  A.  E.  Garrod*  described  five 
cases  of  Mongolism  in  which  congenital  cardiac  lesions  were  found, 
and  one-fifth  of  the  cases  examined  by  Dr.  Sutherland  presented 
well-marked  systolic  basal  murmurs  which  were  evidently  con- 
genital. It  seems  likely  that  these  cases  die  early,  since  heart 
lesions  are  not  very  commonly  found  in  institution  patients.  One 
very  marked  peculiarity  of  these  persons  is  their  tendency  to  chronic 
inflammatory  lesions  of  the  respiratory  and  alimentary  tracts. 
Nasal  catarrh,  bronchitis,  and  diarrhoea  are  exceedingly  common, 
and  the  majority  are  constant  sufferers  from  blepharitis,  rhinitis, 
and  cracked  lips.     The  voice  is  usually  deep  and  gruff. 

Such  are  the  chief  physical  peculiarities  of  this  interesting  variety 
of  amentia.  It  is  rarely  that  they  are  aU  present  in  any  one  person, 
and  there  is  probably  no  one  of  them  which  is  reaUy  pathognomonic 
of  this  condition,  except  perhaps  the  tongue.  This  latter,  with 
the  peculiar  conformation  of  the  skull  and  palpebral  fissures,  the 
cheek  flush,  and  the  general  tendency  to  mucous  catarrh,  seem  to 
me  to  constitute  the  essential  symptom-complex.  As  a  rule  these 
peculiarities  persist  throughout  life ;  but  I  have  seen  a  few  cases  in 
which  advance  of  time  seemed  to  bring  about  a  marked  ameliora- 
tion, and  caused  them  to  become  much  less  evident.  This,  I  think, 
is  more  common  in  the  originally  milder  cases;  but  a  short  time 
ago  Dr.  Caldecott,  of  Earlswood  Asylum,  showed  me  an  imbecile 
whom  the  casual  observer  would  hardly  have  recognized  as  a 
Mongol,  but  who  in  former  years  had  possessed  very  well-marked 
characteristics. 

As  a  rule  Mongols  die  early,  the  average  age  at  death  being 
about  fourteen  years.  They  are  rarely  met  with  above  the  age 
of  thirty  years,  although  at  the  present  time  there  are  two  at 
Normansfield  between  thirty  and  forty ;  and  Dr.  R.  Langdon  Down 
tells  me  that  he  had  a  female  Mongolian  under  his  care  for  many 
years  who  reached  the  advanced  age  of  fifty-seven  years.  The 
chief  cause  of  death  is  some  form  of  tuberculosis,  usually  phthisis. 

Mental  and  Nervous  Condition. — The  mental  characteristics  of 
this  class  are  not  so  distinctive  as  are  the  physical ;  nevertheless 
*  Archibald  E.  Garrod,  British  Medical  Journal,  October  22,  1898. 


Plate  XIV. 
PRIMARY  AMENTIA  (MONGOLIAN  VARIETY). 


Fig.  37. — A  female  Mong-olian.      Age,  3  months. 

{From  a  photograph  lent  by  Dr.  J.  Tlioinson. ) 


Fig.  38. — A  male  Mongolian.  Age,  14  months.  With 
talipes  varus  and  cubitus  varus.  Died  2  months 
later  of  general  tuberculosis. 

{From  a  photograph  lent  l>y  Dr.  J.  Thomson.) 

'To  face  page  21 3.] 


Mongolian  Amentia  (Mongolism)  219 

there  are  several  peculiarities  common  to  them.     From  the  begin- 
ning, the  Mongolian  infant  is  placid,  good-tempered,  and  readily 
amused.     There  is  at  hrst  no  apparent  mental  hebetude;  on  the 
contrary,  he  often  looks  bright  and  intelligent,  has  plenty  of  curi- 
osity, is  attracted  by  everything  around  him,  and  is  very  imitative. 
But  one  of  the  most  common  on  the  early  signs  of  amentia  is  seen  in 
the  tardy  evolution  of  the  power  of  sitting  up,  walking,  and  talking. 
Moreover,  he  is  full  of  grimaces  and  facial  contortions,  which  are 
accompanied  by  wrinkling  of  the  skin,  and  are  foreign  to  the  normal 
child.     As  he  grows  up  the  want  of  intellect  becomes  more  and  more 
apparent.     But  he  still  retains  his  happy  disposition;  he  is  very 
affectionate,  readily  pleased,  apt  to  be  jealous,  likes  to  be  taken 
notice  of,  and  is  usually  a  great  favourite  with  all  around  him.     He 
often  has  a  very  considerable  power  of  mimicry,  as  well  as  a  remark- 
able sense  of  rhythm  and  love  of  music,  and  it  is  quite  common  to 
find  one  of  these  children  amusing  a  group  of  patients  by  his  imita- 
tion of  the  band  conductor,  or  by  the  playing  of  an  imaginary  violin 
or  trombone.     Many  of  these  children  are  adepts  at  drill  and 
dancing. 

The  degree  of  intellectual  deficiency  varies  very  considerably,  and 
on  the  whole  I  am  inclined  to  think  that  there  is  a  direct  relation 
between  this  and  the  intensity  of  the  bodily  signs.  Many  of  them 
are  merely  feeble-minded,  a  few  are  pronounced  idiots,  but  the 
majority  belong  to  the  medium  or  imbecile  grade  of  defect.  The 
milder  members  generally  learn  to  read,  write,  and  perform  simple 
duties  with  a  fair  amount  of  intelligence,  but  their  power  of  summing 
is  decidedly  poor.  Dr.  Shuttleworth  says  that  some  of  these,  after 
appropriate  education,  even  pass  muster  with  their  brothers  and 
sisters.  The  imbeciles,  on  the  other  hand,  rarely  make  much  head- 
way, and,  although  very  imitative,  it  is  not  often  that  in  them  this 
faculty  can  be  turned  to  any  practical  purpose.  In  the  perfonnance 
of  useful  work  they  are  often  surpassed  by  ordinary  imbeciles  of 
far  more  vacant  and  less  prepossessing  appearance.  Even  in  the 
milder  cases  the  clumsy  and  ill-formed  condition  of  the  hands 
usually  precludes  any  kind  of  work  requiring  dexterity,  and  most 
of  these  persons  do  best  in  the  garden  or  on  the  farm.  Their  speech 
is  often  characterized  by  a  persistent  lalling  or  baby  language. 

Cerebral  complications  are  not  common  in  this  class,  and  actual 
paralysis  and  epilepsy  are  rare  in  comparison  with  other  aments. 
It  will  be  seen  that  Mongolian  aments  have  certain  points  in 


2  20     The  Clinical  Varieties  of  Primary  Amentia 

common  with  sporadic  cretins,  and  in  the  early  stages  a  considerable 
number  are  treated  with  thyroid  gland,  and  hopes  of  amelioration 
held  out  to  the  parents,  as  a  result  of  a  mistaken  diagnosis.  The 
chief  points  of  resemblance  are  the  general  backwardness  of  bodily 
development,  with  the  resulting  small  stature,  the  stumpy  and  podgy 
hands  and  feet,  the  squat  nose,  and  the  bogginess  of  the  subcu- 
taneous tissues.  Careful  examination,  however,  will  reveal  far  more 
points  of  difference.  In  the  Mongols  the  head  is  small,  rounded, 
and  brachy cephalic,  instead  of  large  and  dolichocephalic ;  the  tongue, 
although  somewhat  like  that  of  the  cretin  in  being  large  and  pro- 
truding, is  marked  by  hj/pertrophied  papillae,  and  later  by  numerous 
fissures.  The  slant  of  the  eyes,  the  lax  joints,  and  the  chronic 
catarrh  of  the  Mongol  are  very  distinctive;  whilst  his  active,  bright, 
and  vivacious  manner  is  totally  unlike  the  dull,  expressionless  inertia 
of  the  cretin.  In  the  Mongol  the  thyroid  gland  can  usually  be  pal- 
pated readily,  whilst  it  is  absent  in  the  cretin,  and  in  the  latter  small 
fatty  tumours  in  the  posterior  triangle  of  the  neck  will  often  be  felt. 
Finally,  the  rate  of  bodily  growth  is  entirely  different  in  the  two 
conditions.  I  have  known  thyroid  gland,  also  thymus  and  pituitary 
extracts,  given  to  Mongols  persistently  for  years,  but  never  with 
any  appreciable  amelioration  of  the  physical  or  mental  defects; 
whereas,  as  is  well  known,  the  effect  of  thyroid  upon  the  cretin  is 
remarkable. 

THE  COMPLICATIONS  OF  PEIMARY  AMENTIA. 

We  have  described  three  types — namely.  Simple,  Microcephalic, 
and  Mongolian — as  the  chief  clinical  varieties  of  primary  amentia. 
Any  of  these  three,  however,  may  be  complicated  by  certain  severe 
developmental  anomalies  or  special  pathological  conditions  which 
produce  more  or  less  distinctive  clinical  features,  and  these  we  shall 
now  allude  to.     They  are,  in  order  of  frequency: 

Epilepsy. 

Paralysis. 

Hydrocephaliis. 

Porencephahis. 

Sclerosis. 

Deaf -mutism. 

It  is  to  be  remarked  that,  in  the  cases  we  are  now  considering, 
these  conditions  merely  accompany  and  complicate  a  mental  de- 


The   Complications  of  Primary  Amentia     221 

iiciency  which  is  primary.  Similar  lesions  may,  in  a  small  number 
of  instances,  actually  produce  amentia;  but  such,  cases  will  be 
dealt  with  in  a  subsequent  chapter. 

Epileptic  and  Other  Convulsions. — Convulsions  in  some  form  or 
other,  but  chiefly  epileptic,  are  the  most  common  complication  of 
primary  amentia.  A  special  examination  with  regard  to  this  con- 
dition in  over  500  patients  showed  that  in  cases  presenting  no  par- 
alysis or  other  indication  of  gross  cerebral  lesions,  and  in  whom 
therefore  the  attacks  were  probably  idiopathic  epilepsy,  convulsions 
occurred  in  37  per  cent. ;  whilst  in  patients  presenting  signs  of  gross 
lesions  they  occurred  in  70  per  cent.  In  the  great  majority  of  the 
latter,  however,  the  fits  were  indistinguishable  from  ordinary 
epilepsy. 

With  regard  to  the  degree  of  amentia,  it  was  found  that  convul- 
sions occurred  in  11  per  cent,  of  the  feeble-minded,  42  per  cent,  of 
imbeciles,  and  56  per  cent,  of  idiots.  It  is  possible,  however,  that 
these  figures  may  be  somewhat  too  high  for  primary  aments  in 
general,  since  they  largely  relate  to  institution  patients,  and  may 
therefore  contain  an  undue  proportion  of  the  worst  cases.  Con- 
vulsions are  most  frequent  in  the  simple  and  microcephalic  varieties, 
and  are  relatively  rare  in  the  Mongolians. 

With  regard  to  the  convulsions,  as  far  as  could  be  ascertained 
they  were  in  the  great  majority  of  cases  typically  epileptic,  and 
several  of  the  merely  feeble-minded  patients  have  definitely  affirmed 
the  existence  o£  a  premonition  or  aura.  In  the  more  severe  grades 
of  defect  the  mental  condition  usually  precludes  any  inquiry  upon 
this  point,  but  trained  attendants  can  often  foretell  the  onset  of 
a  fit  by  the  appearance  of  the  patient.  Most  of  the  attacks  are  of 
the  major  variety,  although  in  a  few  cases  minor  seizures  occur  also. 
Their  severity  varies  greatly,  some  being  of  the  mildest  possible 
type,  others  exceedingly  severe  and  protracted.  Their  frequency 
is  also  subject  to  great  variation.  In  some  patients  the  first  con- 
vulsion appears  in  the  early  months  of  life,  and  they  thence  con- 
tinue almost  daily  during  the  existence  of  the  patient.  In  other 
instances,  after  frequent  fits  during  many  weeks  or  months  of  early 
childhood,  the  patient  remains  free  for  years,  he  then  has  a  few 
more,  and  these  are  again  followed  by  years  of  quiescence.  In  yet 
other  cases,  after  an  initial  series  of  fits,  there  is  no  recurrence.  I 
have  known  several  persons  who  have  only  experienced  two  or 
three  seizures  in  the  course  of  twenty  years  or  more.     It  is  hardly 


222     The  Clinical  Varieties  of  Primary  Amentia 

safe  to  reckon  on  the  absence  of  epilepsy  in  any  particular  sufferer 
from  primary  amentia,  although  as  a  rule  the  fits  make  their  first 
appearance  not  later  than  the  second  decade. 

The  effect  of  the  convulsions  is  much  the  same  as  in  the 
ordinary  individual,  and  appears  on  the  whole  to  depend  upon  the 
frequency  and  severity  of  the  attacks.  If  severe  and  often  recur- 
ring, the  patient  rapidly  loses  even  his  limited  acquirements ;  whilst 
if  slight  and  seldom,  the  effect  may  be  infinitesimal. 

In  addition  to  epilepsy,  the  following  other  conditions  may  be 
mentioned  as  being  occasionally  seen  in  primary  aments:  Chorea  is 
not  very  common,  but  is  found  in  some  instances.  Various  forms 
of  athetosis  are  fairly  frequent  in  the  severer  grades.  Intention 
tremor  is  occasionally  seen ;  whilst  I  saw  at  Darenth  a  few  years  ago 
two  imbeciles  (brother  and  sister)  affected  with  a  constant  rhythmic 
tremor  of  the  whole  body,  closely  resembling  paralysis  agitans. 
The  tremor  was  so  great  that  articulate  speech  was  impossible ;  the 
fingers  could  not  pick  anything  up,  not  could  they  retain  their  hold 
of  any  object.  In  each  instance  the  tendon  reflexes  were  greatly 
exaggerated,  and  ankle  and  patellar  clonus  were  well  marked,  but 
Babinsky's  sign  was  absent. 

Paralysis. — The  next  most  common  complication  is  paralysis. 
This,  like  epilepsy,  is  least  frequent  in  the  milder,  and  most  so  in 
the  severer,  grades  of  amentia,  and,  generally  speaking,  the  extent 
of  the  paralysis  is  directly  proportionate  to  the  amount  of  mental 
deficiency.  In  a  small  number  of  cases,  particularly  amongst  the 
microcephalics,  the  condition  is  rather  one  of  paresis  and  general 
muscular  hypotonus  and  helplessness  than  of  actual  paralysis,  and 
in  such  it  is  probably  due  to  imperfect  development  of  the  efferent 
pathway.  In  other  instances  it  is  due  to  the  presence  of  a  gross 
cerebral  lesion,  such  as  localized  atrophy,  porencephal3^  or  hydro- 
cephaly. In  these  latter  the  paralysis  is  localized,  and  varies  from 
a  slight  monoplegia  to  a  severe  hemi-  or  para-plegia.  The  affected 
limbs  are  small  and  ill-nourished,  and  often  firml}^  contracted,  and 
many  of  the  worst  cases  are  permanently  chair-  or  bed-ridden.  In 
a  considerable  number  of  these  cases  epileptic  convulsions  also 
occur. 

Hydrocephalus. — Probably  most  cases  of  amentia  in  which  hj-dro- 
cephalus  is  at  all  pronounced  are  of  the  secondary  form,  and  this 
condition,  as  well  as  porencephalus  and  sclerosis,  will  be  more  fully 
described  in  a  subsequent  chapter.     But  a  few  undoubted  primary 


The  Complications    of  Primary    Amentia     223 

aments  develop  hydrocephalus  with  its  characteristic  sj^mptoms, 
and  the  condition  is  not  infrequently  found  post-mortem  where  it 
had  not  been  suspected  during  life. 

Marked  hydrocephalus  usually  produces  enlargement  of  the  skull 
(macrocephaly) ;  but  this  latter  condition  may  arise  from  so  many 
other  causes  that  it  does  not  seem  to  me  to  merit  description  as  a 
separate  clinical  variety,  as  is  the  case  with  microcephaly. 

Porencephalus. — True  or  false  porencephaly  is  sometimes  found 
post-mortem  when  there  has  been  little  indication  of  its  existence 
during  life.  It  cannot  be  diagnosed  with  certainty,  but  its  presence 
maybe  suspected  in  cases  of  congenital  hemiplegia  which  are  accom- 
panied by  considerable  non-development  of  the  affected  limbs  and 
marked  flattening  of  the  opposite  half  of  the  skull. 

Sclerosis. — The  usual  indications  of  this  complication  are  fre- 
quently repeated  con\ailsions,  followed  by  muscular  tremor,  weak- 
ness, or  actual  paralysis  with  contractures.  In  some  cases  there  is 
persistent  headache,  the  patient  becomes  more  and  more  torpid 
and  dies  after  a  succession  of  severe  fits. 

Deaf-Mutism  is  seen  in  a  small  proportion  of  primary  aments. 
It  calls  for  no  remark  beyond  the  fact  that  such  a  complication 
naturally  imposes  an  insuperable  barrier  to  successful  training.  On 
the  other  hand,  the  mild  mental  defect  which  results  from  this  con- 
dition is  greatly  ameliorated,  and  in  many  cases  removed,  by 
appropriate  education. 


CHAPTER  XIII 
SECONDARY  AMENTIA  AND  ITS  CLINICAL  VARIETIES 

Hitherto  we  have  been  concerned  with  the  primary  form  of 
amentia,  in  which  the  imperfection  of  mental  development  is 
due  to  innate  defects  of  the  germ  cell.  In  the  present  chapter  we 
have  to  deal  with  that  small  proportion  of  cases  (probably  not  more 
than  about  lo  or  15  per  cent,  of  all  aments)  in  which  there  is  no 
such  inherent  defect ;  but  in  which  the  development  of  a  portion 
of  the  brain  has  been  arrested  by  some  external  cause.  This  form, 
as  already  mentioned,  is  termed  Secondary  Amentia. 

In  many  instances  the  distinction  is  obvious,  alike  from  the 
family  and  personal  history,  the  morbid  anatomy,  and  the  clinical 
appearances ;  but  it  is  necessary  to  remember  that  primary  aments 
may  suffer  from  superadded  complications  similar  to  those  producing 
arrest  in  the  secondary  form;  also  that  some  primary  aments, 
although  labouring  under  a  defective  potentiality  for  mental 
development,  may  appear  to  be  progressing  normally  until  the 
advent  of  some  physiological  epoch  or  slight  pathological  disturb- 
ance suffices  to  make  their  innate  defect  manifest.  These  latter 
cases  in  a  sense  form  an  intermediate  group,  and  have  been  termed 
"  developmental  "  or  "  delayed  primary  "  amentia. 

With  the  above  exception  there  is  a  marked  difference  in  the 
clinical  aspects  of  the  primary  and  secondary  forms.  The  inherent 
blight  of  the  former  gives  rise  to  numerous  and  widespread  anomalies 
of  anatomical  development  which  are  absent  in  the  latter.  As  a 
consequence,  the  sufferer  from  secondary  amentia  is  often  readily 
distinguished  from  the  primary  ament  by  being  well  developed  and 
well  grown,  and  by  his  comely  and  prepossessing  appearance, 
although  occasionally  there  are  deformities  and  abnormalities  de- 
pendent upon  the  particular  pathological  lesion  present.  Further, 
whilst  in  uncomplicated  cases  of  the  primary  group  the  general  ten- 

224 


Amentia  due  to  Gross  Cerebral   Lesions     225 

dency  is  for  some  degree  of  amelioration  to  take  place  as  a  result 
of  suitable  training,  many  of  those  of  the  class  we  are  now  consider- 
ing are  the  result  of  cerebral  lesions  which  are  progressive,  and  the 
tendency  is  rather  towards  degeneration  and  ultimate  dementia. 

Cases  of  secondary  amentia  may  conveniently  be  divided  into 
two  main  classes.  In  the  first  of  these  the  mental  deficiency  is 
brought  about  by  a  gross  lesion  of  the  brain ;  in  the  second  it  is  due 
to  some  external  factor  influencing  cerebral  nutrition.  Each  of  these 
classes  contains  several  clinical  varieties.  This  chapter  will  there- 
fore be  divided  into  two  sections,  as  follows: 

SECTION  I. 

Amentia  due  to  Gross  Cerebral  Lesions. 

Toxic,  Inflammatory  and  Vascular  Amentia,  including  certain  clinical 
subvarieties — viz. : 

{a)  Sclerotic, 
(fe)    Hydrocephalic, 
(c)    Syphilitic. 
{d)  Amaurotic. 

SECTION  II. 

Amentia  due  to  Defective  Cerebral  Nutrition. 

1.  Epileptic  and  eclampsic  amentia. 

2.  Cretinism. 

3.  Amentia  due  to  malnutrition. 

4.  Amentia  due  to  sense  deprivation. 

It  may  be  well  again  to  emphasize  the  fact  that,  although  many 
of  the  etiological  and  pathological  conditions  present  in  secondary 
amentia  may,  and  frequently  do,  complicate  the  primary  form,  we 
are  only  here  concerned  with  such  cases  of  amentia  as  are  directly 
and  entirely  attributable  to  them.  The  reason  for  including  epileptic 
amentia  in  this  place  has  been  given  on  p.  96. 


Section  I. 

AMENTIA  DUE  TO  GROSS  CEREBRAL  LESIONS. 

The  cases  comprised  within  this  section  owe  their  amentia  to 

some  vascular  or  toxic  process  within  the  brain.     In  a  considerable 

number  of  instances  degenerative  changes  sooner  or  later  supervene, 

in  consequence  of  which  dementia  becomes  added  to  the  mental 

■  deficiency. 

15 


226     Secondary  Amentia  and  its  Clinical  Varieties 


TOXIC,  INFLAMMATORY  AND  VASCULAR  AMENTIA. 

There  are  many  substances  which  act  as  poisons  upon  the  body- 
cells.  For  instance,  there  is  the  inorganic  group,  well-known  ex- 
amples of  which  are  arsenic,  lead,  and  phosphorus.  There  is  the 
organic  group,  instances  of  which  are  alcohol,  carbon  monoxide,, 
and  hydrocyanic  acid.  Lastly,  there  is  the  group  of  toxins  produced 
by  the  action  of  micro-organisms.  It  is  these  last  which  we  find 
to  be  chiefly  concerned  in  the  causation  of  amentia.  In  some  in- 
stances the  affection  of  the  brain  is  secondary  to  some  acute  process 
elsewhere,  such  as  pneumonia,  influenza,  enteric,  otitis,  or  rhinitis; 
but  in  others  the  brain  would  appear  to  be  involved  primarily.  The 
pathological  process  usually  consists  of  either  a  lepto -meningitis  or 
a  polio-encephalitis  (as  described  by  Striimpell),  and,  as  pointed 
out  by  Oppenheim,*  this  latter  closely  resembles  the  acute  inflam- 
mation which  occurs  in  the  anterior  horns  of  the  spinal  cord.  I  am 
inclined  to  think  that  many  cases  of  amentia  due  to  "  meningitis  " 
of  obscure  origin,  or  to  so-called  "sunstroke,"  or  even  "  fright," 
may  really  belong  to  one  or  other  of  these  groups. 

In  most  instances  the  affection  occurs  within  the  early  years  of 
childhood,  but  the  fact  that  pathological  changes,  consisting  chiefly 
of  numerous  small  foci  of  haemorrhage  and  softening  similar  to  those 
occurring  in  polio-encephalitis,  may  be  found  at  birth,  points  to 
the  possibility  of  a  prenatal  infection,  f 

The  clinical  course  of  the  illness  is  subject  to  considerable  varia- 
tion. In  a  proportion  of  cases  prodromal  symptoms  are  present, 
the  infant  or  child  being  listless  and  suffering  from  malaise  for  two- 

*  Oppenheim,  Deuisch.  Zeit.f.  Nervenheilk.,  Band  vi.,  1895. 

t  Dr.  G.  Sutherland  and  Mr.  H.  W.  Perkins  recently  showed  a  case  which 
I  take  to  be  somewhat  of  this  nature  before  the  Royal  Society  of  Medicine 
(November,  1912).  The  patient  was  a  female  child  who  lived  for  nine  weeks, 
and  on  opening  the  skull  about  9  ounces  of  blood-stained  fluid  escaped. 
The  brain  was  very  small,  and  covered  with  thickened,  cedematous-looking 
pia-arachnoid,  on  the  removal  of  which  the  cerebral  lobes  were  found  to  be 
extremely  ill-developed.  The  total  weight  of  the  brain  was  only  80  grammes. 
Dr.  Sutherland  was  good  enough  to  place  several  microscopical  sections  of 
the  brain  at  my  disposal  for  examination,  and  I  found  a  svv'ollen  and  infil- 
trated pia  and  numerous  small  foci  of  softening  throughout  the  brain  cortex. 
The  nerve  cells  were  fewer  in  number,  and  very  incompletely  developed- 
and  in  places  showed  signs  of  degeneration.  Had  such  a  child  lived,  it  would- 
have  been  a  hopeless  idiot. 


Toxic,  Inflammatory  and  Vascular  Amentia     227 

or  three  days  before  any  cerebral  symptoms  make  their  appearance. 
In  most  cases,  however,  the  onset  is  much  more  rapid,  and  he  is 
suddenly  seized  with  headache,  vomiting,  and  fever,  speedily  fol- 
lowed by  unconsciousness  or  restless  delirium,  convulsions,  and 
often  paralysis.  The  pain  in  the  head  is  usually  ver}^  severe,  and 
is  a  marked  feature ;  pain  in  the  back  is  also  often  complained  of. 
The  respiration  is  apt  to  be  slow  and  irregular;  the  pulse  maybe 
slow  or  rapid,  but  is  usually  feeble.  The  temperature  rarely  rises 
to  more  than  102°  or  103°  F.  The  convulsions  are  general,  and 
resemble  those  of  epilepsy.  Sometimes  they  are  continuous,  so  that 
a  status  epilepticus  results;  but  in  other  cases  they  occur  as  isolated 
fits,  the  patient  being  either  delirious  or  comatose  between  whiles. 
Paralysis  may  be  noticed  at  the  onset,  or  it  may  not  appear  until  a 
few  days  afterwards,  and  it  may  be  absent  entirely.  When  present 
it  usually  consists  of  monoplegia  or  hemiplegia;  diplegia  is  rare. 
The  reflexes  are  increased;  but  there  is  rarely  any  marked  disturb- 
ance of  sensation.  The  symptoms  follow  no  definite  course,  and 
differ  considerably  in  different  patients ;  but  they  are  always  such 
as  to  make  it  quite  obvious  that  the  child  is  seriously  ill,  and  that 
the  seat  of  the  trouble  is  the  brain  or  its  meninges.  These  symptoms 
are  practically  the  same  whether  the  brain  is  affected  primarily,  or 
whether  it  is  involved  in  the  course  of,  or  a  few  weeks  after,  some 
other  condition,  such  as  influenza  or  pneumonia. 

In  a  few,  but  I  think  a  very  few,  cases  the  child  recovers  com- 
pletely. In  others,  after  an  illness  of  ten  or  fourteen  days,  there  is 
a  marked  change  for  the  worse;  the  pupils  dilate,  the  pulse  and  res- 
piration become  more  irregular,  the  coma  deepens,  and  the  patient 
dies.     Sometimes  the  end  comes  after  a  series  of  convulsions. 

In  yet  other  cases  the  fever  gradually  abates,  the  convulsions  cease, 
or  continue  only  at  rare  intervals,  the  child  recovers  consciousness, 
and  some  amount  of  improvement  takes  place  in  the  paraU'sis. 
But  the  psychic  functions  have  been  damaged.  An  impairment  of 
the  intellect  may  be  noticed  immediately  on  the  subsidence  of  the 
acute  symptoms,  or  it  may  only  appear  as  the  child  begins  to  get 
about  and  to  mix  with  his  companions.  If  the  child  had  begun  to 
speak,  he  may  now  be  speechless.  His  disposition  may  be  altered, 
so  that  the  persons,  the  playmates,  and  the  games  of  which  he  was 
formerly  fond  are  now  distasteful  to  him.  With  this  there  is  either 
unusual  irritability  or  apathy  and  dullness,  and  examination  speedily 
shows  the  presence  of  intellectual  impairment.     As  time  goes  on 


228      Secondary  Amentia  and  its  Clinical  Varieties 

this  is  seen  more  and  more  in  the  difficulty  he  experiences  in  learning. 
In  a  few  cases  recovery  from  the  illness  at  first  appears  to  be  com- 
plete, at  any  rate  to  the  parents,  and  it  is  only  after  a  time,  when 
the  child  begins  to  go  to  school,  that  he  is  found  to  be  incapable 
of  mental  application  and  of  progressing  with  his  studies.  Incurable 
deaffiess  is  not  uncommon  in  cases  of  this  kind.  •  With  regard  to  the 
degree  of  defect  the  brain  lesion  may  be  so  severe  that  the  child 
is  rendered  idiotic  from  the  beginning ;  in  other  instances  it  is  much 
less  serious,  but  the  patient  cannot  keep  abreast  of  his  compeers, 
and  as  time  goes  on  he  is  left  farther  and  farther  behind  in  a  state 
of  incurable  feeble-mindedness.  I  cannot  say  what  proportion  of 
children  who  have  suffered  from  encephalitis  or  meningitis  are  thus 
rendered  permanently  weak-minded.  No  doubt,  as  I  have  remarked, 
very  many  of  them  die,  whilst  a  few  seem  to  recover  completely; 
but  the  likelihood  of  interference  with  brain  development  is  so 
great  that  the  utmost  caution  should  be  exercised  in  giving  a  prog- 
nosis. 

The  fact  that  the  onset  of  these  cases  is  so  often  attended  with 
convulsions  causes  them  to  be  frequently  designated  "  epileptic  " 
or  "  eclampsic  "  amentia,  whereas  the  convulsions  are  in  reality  a 
symptom  and  not  a  cause. 

In  addition  to  the  arrest  of  cortical  development  brought  about  by 
toxins,  cerebral  lesions  may  be  produced  and  growth  interfered  with 
by  haemorrhage,  thrombosis,  and  embolus;  also  by  trauma.  It 
is  this  class  we  have  now  to  consider.  The  commonest  cause  of 
these  lesions  is  unquestionably  hcemorrhage.  Embolus  of  a  cerebral 
vessel  may  occur  in  young  infants  suffering  from  rheumatic  endo- 
carditis; and  Sir  William  Gowers  has  shown  the  importance  of 
venous  thrombosis,  which  may  occur  in  asphyxia  neonatorum  or 
be  part  of  a  sinus  thrombosis  happening  after  birth;  but  both 
embolus  and  thrombus  are  relatively  rare,  and  it  is  haemorrhage 
which  is  responsible  for  the  greater  proportion  of  cases  in  this  group. 
The  haemorrhage  is  generally  meningeal,  and  may  occur  before, 
during,  or  after  birth.  The  cases  arising  before  birth  are  usually 
ascribed  to  trauma,  but  their  causation  is  by  no  means  clear.  The 
cause  during  birth  is  usually  the  prolonged  pressure  incident  to  a 
protracted  labour  (Little's  disease),  but  haemorrhage  may  occasion- 
ally follow  precipitate  labour.  The  forceps  have  often  been  blamed 
for  the  bleeding,  but  it  is  very  doubtful,  to  my  mind,  whether  skil- 
fully applied  forceps  have  ever  of  themselves  produced  serious 


Toxic,  Inflammatory  and  Vascular  Amentia      229 

injury  to  the  brain,  although  their  unskilful  use  may  do  so.  After 
birth  hsemorrhage  may  result  from  a  direct  injury  in  the  shape  of 
a  fall  or  blow,  or  it  may  occur  during  a  severe  paroxysm  of  whooping- 
cough;  whilst  trauma  maj^  result  in  a  laceration  of  cortical  tissue 
without  pronounced  haemorrhage. 

In  the  great  majority  of  the  birth  cases,  which  is  by  far  the  most 
numerous  group,  the  child  presents  well-marked  asphyxia  when 
born,  from  which  he  is  resuscitated  with  considerable  difficulty. 
For  several  days  he  remains  torpid,  with  feeble  pulse  and  respira- 
tion, tense  anterior  fontanelle,  and  contracted  pupils.  He  does  not 
cry,  and  requires  much  rousing  before  he  will  take  food.  His 
muscles  are  rigid,  opisthotonos  may  be  present,  and  convulsions  are 
frequently  seen.  A  little  later  on  evidence  of  paralysis  in  one  or 
more  limbs  is  noticed.  Sitting  up,  walking,  and  first  attempts  at 
speech  are  all  delaj^ed,  and  it  is  gradually  borne  in  upon  the  parents 
that  the  child's  mind  is  not  quite  the  same  as  that  of  other  children. 
In  the  milder  cases  the  initial  syrnptoms  may  rapidly  pass  off,  and 
it  is  only  when  the  child  begins  his  schooling  that  deficiency  is 
noticed,  and  that  he  is  found  to  be  unable  to  make  any  mental 
effort. 

Paralysis  is  a  very  common  feature  of  these  cases.  Jacksonian 
or  epileptic  convulsions  occur  in  a  considerable  proportion;  whilst 
athetoid  or  choreiform  movements  are  also  frequently  seen.  There 
is  usually  some  flattening  of  the  skull  over  the  affected  side.  Many 
of  these  children  are  small  and  delicate,  and  there  is  no  doubt  that 
a  large  proportion  die  in  the  early  years  of  life,  some  of  convulsions, 
others  of  ordinary  children's  ailments.  But  others  thrive  and  get 
fat,  and  may  live  for  many  years.  There  is  not  as  a  rule  any  pro- 
nounced sensory  disturbance,  although  sometimes  hearing  is  im- 
paired. The  amentia  varies  from  a  mild  degree  of  feeble-minded- 
ness  to  gross  inarticulate  idiocy. 

Factors  influencing  the  Causation  of  Amentia  in  Toxic  and  Vascular 
Lesions. — I  have  dealt  with  the  toxic  and  vascular  cerebral  lesions 
separately  up  to  this  point,  because  at  their  onset  they  present  marked 
clinical  differences;  we  may  now  consider  some  points  applicable 
to  both  of  them.  It  is  probable  that  the  total  number  of  children 
affected  in  one  or  other  of  the  modes  described  is  not  inconsider- 
able, and  where  such  s^onptoms  are  at  all  severe,  the  majority 
die.  Others,  but  relatively  few,  appear  to  make  a  complete  re- 
covery.    In  yet  others  death  does  not  take  place,  but  a  permanent 


230     Secondary  Amentia  and  its  Clinical  Varieties 

legacy  remains  in  the  shape  of  a  gross  cerebral  lesion.  It  is  this 
latter  group  with  which  we  are  here  concerned. 

It  is  by  no  means  to  be  assumed  that  the  child  who  emerges  from 
an  illness  of  this  kind  with  a  gross  lesion  of  the  brain  will  necessarily 
be  mentally  defective.  The  effect  of  the  lesion  upon  the  patient 
varies  very  much,  and  in  the  main  three  phenomena  may  result, 
either  singly  or  in  combination — namely,  paralysis,  epilepsy,  and 
amentia. 

It  is  sometimes  stated  that  if  paralysis  results  from  these  lesions 
it  is  sure  to  be  accompanied  by  some  amount  of  mental  deficiency. 
This  is  a  complete  mistake;  not  only  may  marked  paralysis  occur 
without  amentia,  but  amentia  may  be  present  without  paralysis. 
I  have  seen  quite  a  considerable  number  of  cases  in  which  there  was 
paralysis  of  hand  and  forearm  or  foot  and  leg,  or  even  of  two  limbs, 
without  the  slightest  intellectual  impairment;  indeed,  in  some  of 
them  the  mental  capacity  was  decidedly  above  the  average.  Dr. 
Sigmund  Freud,*  who  has  made  a  most  careful  study  of  the  ques- 
tion, says:  "  Idiocy  does  not  show  any  constant  relationship  to  the 
other  signs  of  infantile  cerebral  paralysis  in  respect  of  the  degree 
of  psychic  arrest.  There  are  cases  of  the  severest  paralysis  with 
the  intelligence  scarcely  affected,  as,  on  the  other  hand,  complete 
idiots  without  any  signs  of  paralysis." 

With  regard  to  epilepsy  the  case  is  somewhat  different,  and 
where  the  initial  pathological  process  is  such  as  to  produce  fre- 
quently repeated  convulsions,  there  is  a  strong  probability  that 
some  degree  of  amentia  wiU  result,  and  that  dementia  will  ultimately 
supervene.  But  in  these  cases  this  result  is  by  no  means  invariable, 
and  it  occasionally  happens  even  in  them  for  intellectual  develop- 
ment to  show  no  sign  whatever  of  having  been  adversety  affected. 
In  exceptional  cases  it  may  even  happen  for  the  mind  to  show  no 
trace  of  defect  where  both  paralysis  and  epilepsy  are  present.! 

*  Freud,  "  Infantile  Cerebrallahmung,"  Wien,  1897. 

I  A  good  example  of  this  was  described  by  the  writer  in  an  article  on 
"  Amentia  "  in  Mott's  "  Archives  of  Neurology,"  vol.  ii.  In  this  case  there 
was  right  hemiplegia,  with  constant  epileptic  fits  from  birth,  probably  due 
to  asphyxia  neonatorum.  The  patient  died,  aged  thirty-five  years,  from 
exhaustion  following  a  series  of  fits,  and  post-mortem  examination  revealed 
chronic  meningo-encephalitis  of  the  whole  of  the  motor  region  of  the  left 
hemisphere.  There  was  also  considerable  non-development  of  this  hemi- 
sphere, its  weight  being  105  grammes  less  than  the  right,  and  there  was 
chronic  interstitial  sclerosis,  with  diminished  number  of  nerve  fibres,  through- 
out the   corresponding   upper   efferent  tract.     The   motor   lesion   had   been 


Toxic,  Inflammatory  and  Vascular  Amentia     231 

Finally,  in  a  certain  number  of  cases  these  infantile  lesions  give  rise 
to  amentia,  with  or  without  either  or  both  paralysis  and  epilepsy. 
It  is  thus  seen  that  these  infantile  cerebral  lesions  are  attended  with 
widely  different  results,  and  although  in  this  place,  of  course,  we 
are  only  concerned  with  those  in  which  amentia  occurs,  it  will  not 
be  out  of  place  to  consider  the  reason  for  such  diversity. 

Two  possible  factors  influencing  the  result  are  the  age  of  the 
patient  when  the  lesion  occurs  and  the  inherited  potentiality  of  the 
neuroblasts.  In  the  new-born  child  cortical  lamination  is  not  yet 
complete,  and  there  are  a  large  number  of  neuroblasts  tying  among 
more  fully  developed  nerve  cells.  I  am  inclined  to  think  that  a 
considerable  number  of  these  never  attain  mature  development,  for 
such  immature  cells  may  often  be  found  in  middle  life.  In  this,  as 
in  other  matters.  Nature  seems  to  act  lavishly,  and  to  provide  a 
far  greater  nmnber  of  cells  than  are  developed  by  the  stimulus  of 
incoming  sensations  which  comprise  "  education."  In  fact,  there 
appears  to  be  a  potentiality  for  cerebral  development  exceeding 
that  usually  attained  by  the  individual ;  in  other  words,  a  develop- 
mental reserve  which  is  never  fully  drawn  upon.  With  the  lapse  of 
years,  doubtless,  this  capacity  of  the  embryonic  cells  becomes  progres- 
sively less,  and  hence  the  older  the  child  the  more  serious  is  likely 
to  be  the  result  of  one  of  these  lesions.  Before  cortical  lamination 
is  complete,  however,  I  see  no  reason  why  their  inherent  potentiality 
should  be  inferior  to  others  amid  which  they  lie.  Consequently  it 
is  not  improbable  that  the  destruction  of  nerve  cells  caused  by  a 
lesion  occurring  at  or  shortly  after  birth  may  be  compensated  by  the 
development  of  these  embryonic  cells;  and  where  the  two  hemi- 
spheres have  a  function  in  common,  it  may  even  be  possible  for  such 
compensation  to  take  place  in  the  opposite  side  to  the  one  affected. 
This  view,  of  course,  is  largely  hypothetical,  but  it  finds  support  in 
a  number  of  clinical  facts  which  are  otherwise  extremely  puzzling.* 
Thus,  many  cases  have  been  recorded  in  which  the  greater  part  of 

compensated  to  a  great  extent  by  a  numerical  increase  of  Betz'  cells  of  the 
opposite  hemisphere.  And  yet  this  patient  showed  no  trace  of  amentia, 
and,  in  spite  of  his  paralysis  and  epilepsy,  was  able  to  earn  his  living  until 
nearly  twenty  years  of  age.  He  was  then  admitted  to  the  workhouse  in 
consequence  of  the  fits,  and  subsequently  transferred  to  the  asylum  on 
account  of  post-epileptic  insanity.  At  the  time  of  his  death  there  was  prac- 
tically no  dementia. 

*  Dr.  G.  Anton  has  drawn  attention  to  the  possibility  of  compensation 
thus  taking  place  in  the  opposite  hemisphere  in  an  interesting  article  in  Monats. 
/.  Psychiat.,  January,  1906. 


232     Secondary  Amentia  and  its  Clinical  Varieties 

one  cerebral  hemisphere  was  practically  useless  by  reason  of  por- 
encephaly or  hemiatrophy,  and  yet  the  mental  and  motor  defect 
was  but  slight ;  indeed,  in  a  large  number  of  these  cases  the  clinical 
signs  (particularly  of  paralysis)  are  astonishingly  insignificant  when 
compared  with  the  state  of  the  encephalon.*  Moreover,  in  the  case 
already  referred  to,  where  practically  all  the  large  motor  cells  (of 
Betz)  of  the  left  leg  area  had  been  destroyed  by  a  vascular  lesion 
during  birth,  I  was  able  to  demonstrate  a  compensatory  increase  in 
the  corresponding  cells  of  the  opposite  hemisphere. 

A  diminished  neuronic  potentiality,  due  to  slight  morbid  heredity, 
is  the  explanation  of  those  cases  of  so-called  "  developmental " 
amentia  which  apparently  result  from  a  comparatively  trifling 
cerebral  lesion  or  general  disturbance  of  health,  and  in  all  prob- 
ability in  the  cases  we  are  now  considering  the  effect  of  these  lesions 
upon  the  inteUectual  capacity  of  the  patient  is  in  no  little  measure 
influenced  by  his  hereditary  predisposition.  One  would  also 
imagine  that  the  ultimate  amount  of  physical  or  psychic  impairment 
in  these  cases  would  be  considerably  influenced  by  the  amount  of 
special  training  received  by  the  patient  during  infancy. 

With  regard  to  the  kind  of  lesion,  there  is  so  much  variation  that 
I  find  it  very  difiicult  to  make  a  precise  statement ;  but  my  general 
experience  is  that  mental  deficiency  is  more  likely  to  occur,  and  to 
be  more  severe,  in  the  toxic  than  in  the  vascular  cases.  This  may 
not  be  due  so  much  to  the  nature  of  the  lesion,  however,  as  to  the 
age  at  which  it  occurs ;  for  most  of  the  vascular  cases  occur  at  birth ; 
but  the  toxic  ones  not  until  the  early  years  of  childhood,  when  com- 
pensation is  much  less  likely  to  result. 

Another  very  important  factor  influencing  the  prognosis  in  these 
cerebral  lesions  is  their  situation  and  extent.  If  confined  to  the 
motor  cortex  or  its  downward  prolongations,  the  result  wiU  probably 

*  On  this  subject  see  a  very  interesting  article  on  "  Secondarj-  Degenera- 
tion following  Cerebral  Lesions,"  by  W.  G.  Spiller  {Journal  of  Nervous  and 
Mental  Disease,  New  York,  January-,  1898).  Dr.  Spiller  describes  the  case 
of  a  boy  in  whom  "  the  motor  fibres  of  the  left  cerebral  hemisphere  were 
totally  destroj'ed,  and  yet  the  boy  was  able  to  walk  without  a  crutch,  although 
in  an  imperfect  manner;  he  had  no  use  of  the  right  upper  hmb."  Spiller 
says:  "  The  conviction  is  forced  upon  one  that  the  motor  fibres  to  the  right 
lower  hmb  were  transmitted  through  the  pyramidal  fibres  from  the  right 
cerebral  hemisphere.  .  .  .  The  nervous  system  can  adapt  itself  much  better 
to  altered  circumstances  if  destruction  of  tissue  occurs  before  the  nerve 
cells  and  fibres  are  fully  formed,  and  it  would  seem  that  even  additional 
fibres  may  develop."  He  quotes  several  similar  cases  which  have  been 
recorded  by  vcn  Monakow,  Mahaim,  Dejerine,  Thomas,  and  Zacher. 


Toxic,  Inflammatory  and  Vascular  Amentia      233 

be  paralysis  without  amentia.  In  a  considerable  number  of  cases, 
however,  lesions  of  the  motor  cortex  also  produce  convulsions  which 
may  at  first  be  Jacksonian,  and  ultimately  become  typically  epi- 
leptic. It  may  even  happen  for  a  subcortical  focus  of  disease  to 
produce  similar  convulsions.*  As  a  consequence  of  these  convul- 
sions amentia  and  dementia  may  be  induced.  A  lesion  in  or  near 
the  motor  cortex  may  exceptionally  ca,use  epilepsy  without  paral- 
ysis, and  here  also  the  convulsions  may  bring  about  subsequent 
mental  deterioration;  in  such  cases  paralysis  may  supervene  later. 
A  lesion  elsewhere  may  give  rise  to  epilepsy,  either  by  acting  as  a 
source  of  reflex  irritation,  or  by  causing  an  increased  intracranial 
pressure.  Finally,  a  lesion  of  the  more  purely  psychic  areas  (prob- 
ably the  frontal,  prefrontal,  and  parietal  lobules)  may  produce 
amentia  without  either  paralysis  or  epilepsy.  It  js  necessary  to 
remember  that  not  only  may  secondary  pathological  changes  be 
induced  by  any  of  these  lesions,  but  that  an  arrest  of  development 
may  occur  in  far-removed  portions  of  the  encephalon  which  are 
functionally  correlated.  The  involvement  of  both  hemispheres,  as 
shown  by  diplegia  or  paraplegia,  is  of  far  more  serious  import  than 
where  one  side  only  is  affected. 

In  view  of  the  widely  differing  effects  of  these  cerebral  lesions,  it 
is  obvious  that  no  accurate  forecast  is  possible.  Of  the  children 
born  with  asphyxia,  the  number  in  whom  amentia  results  is  exceed- 
ingly small,  and  careful  observation  of  the  child  for  a  few  days  will 
usually  enable  the  physician  to  reassure  the  parents  on  this  head. 
Of  the  cases  happening  during  early  childhood,  the  proportion  who 
become  aments  is  much  larger,  and  this  possibility  can  never  with 
certainty  be  excluded  until  the  lapse  of  some  time  after  the  illness. 
If  diplegia  or  paraplegia  be  present,  then  it  is  highly  probable  that 
some  degree  of  mental  deficiency  will  result.  Apart  from  this» 
however,  the  degree  of  paralysis  affords  no  indication  as  to  the 
amount  of  psychic  damage.  There  may  be  extensive  hemiplegia 
with  no  inteUectual  defect,  or  there  may  be  profound  amentia'vvith 
but  trifling  or  even  no  paralysis  at  all.  Even  were  one  able  to 
exclude  all  involvement  of  the  psychic  areas,  there  would  still  be 
the  possibility  of  recurrent  epilepsy,  and  the  consequent  induction 
of  amentia  and  dementia. 

The  mental  deficiency  in  these  cases  may  be  slight  or  severe. 

*  Such  a  case  was  described  by  the  author  in  Mott's  "  Archives  of  Neu- 
rology," vol.  i. 


234     Secondary  Amentia  and  its  Clinical  Varieties 

Some  patients  are  merely  feeble-minded,  and  beyond  a  general 
simplicity  and  childishness,  an  inability  to  get  on  at  school  and  to 
fend  for  themselves,  they  are  capable  of  a  considerable  amount  of 
useful  work  under  supervision.  Others  belong  to  the  imbecile 
grade,  and  are  capable  of  very  little;  others  are  idiots.  In  some 
persons  the  defect  seems  to  be  more  particularly  marked  in  certain 
faculties;  thus,  we  find  that  in  some  the  memory  is  chiefly  affected, 
in  others  the  attention  or  the  power  of  speech.  In  disposition  and 
behaviour  some  of  these  aments  are  placid,  contented,  affectionate, 
and  trustworthy,  but  others  are  very  emotional  and  undependable. 
I  am  inclined  to  think  that  a  suspicious  disposition  and  general 
irritability  of  temper,  together  with  a  liability  to  be  easily  upset  and 
to  commit  impulsive  actions,  are  very  common  characteristics  of 
patients  suffering  from  these  varieties  of  amentia.  As  already  re- 
marked, there  are  no  stigmata  of  degeneracy,  and  in  such  of  these 
persons  as  are  not  paralyzed  the  bodily  development  and  nutrition 
are  usually  good.  Often,  indeed,  as  Langdon  Down  said,  they  are 
of  winsome  and  comely  appearance. 

It  is  impossible  to  formulate  more  than  very  general  rules  as  to 
the  prospects  of  improvement  in  these  cases.  On  the  whole,  if  the 
case  is  really  a  secondary  one,  and  not  a  case  of  primary  amentia 
complicated  by  a  gross  cerebral  lesion,  and  if  convulsions  are  not 
frequent,  there  is  a  likelihood  of  a  fair  amount  of  improvement  under 
proper  educational  methods.  But  such  training  must  be  begun 
early  to  be  of  much  avail,  and,  unfortunately,  one  finds  a  very  great 
tendency  to  postpone  it  until  too  late,  under  a  mistaken  trust  that 
the  child  will  "  grow  out  of  it."  The  extent  of  paralysis  is  no 
criterion  as  to  the  possibility  of  improvement.  Some  of  the  most 
hopeless  cases  are  those  in  whom  there  is  no  paralysis,  whilst  some 
of  those  who  suffer  from  a  severe  physical  handicap  may  be  taught 
to  perform  really  useful  work.  Recurring  convulsions  are  of  much 
more  unfavourable  import. 

Paralytic  Aments. — In  a  large  proportion  of  these  vascular  and 
toxic  cases  paralysis  is  present,  and  such  may  conveniently  be 
described  as  paralytic  aments.  The  amount  of  paralysis  varies 
enormously,  ranging  from  a  partial  monoplegia  to  a  hemi-,  di-,  or 
para-plegia.  In  some  cases  the  only  observable  defect  may  be  a 
want  of  opposition  of  the  thumb  of  one  side;  in  others  there  is  a 
severe  hemiplegia,  accompanied,  it  may  be,  by  some  weakness 
of  the  opposite   foot.     In  the  birth  or  asphyxial  cases,   double 


Toxic,   Inflammatory  and  Vascular  Amentia     235 

talipes  equino-varus  is  not  uncommon ;  both  legs  may  be  completely 
paralyzed,  and  occasionally  spastic  paresis  of  the  legs  may  be  accom- 
panied by  an  inability  to  perform  certain  fine  movements  of  the 
hands.  As  a  rule  the  face  and  tongue  are  not  involved.  In  addi- 
tion to  being  paralyzed,  the  affected  limbs  are  much  smaller  than 
the  corresponding  healthy  ones,  and  may  be  cold  and  livid.  In 
course  of  time  rigidity  and  shortening  take  place,  with  the  develop- 
ment of  contractures  and  abnormal  postures.  The  reflexes  are 
usually  exaggerated,  and  Babinsky's  toe  sign  is  frequently  present. 

In  some  paralytic  aments  convulsions  are  a  prominent  feature. 
As  a  rule,  in  their  onset,  course,  and  post-convulsive  state  these  are 
indistinguishable  from  those  of  ordinary  idiopathic  epilepsy;  but 
in  some  cases  they  are  of  a  Jacksonian  character.  In  one  of  my 
patients  both  localized  and  general  convulsions  occurred,  the  former 
unattended  by  loss  of  consciousness ;  but  they  gradually  passed  into 
the  typical  epileptic  variety,  and  I  think  this  is  the  tendency  in 
most  of  these  cases  where  the  fits  begin  as  Jacksonian.  Sometimes 
paralysis  may  exist  for  years  without  any  fits,  and  then  epilepsy 
suddenly  makes  its  appearance.  Petit  mal  also  occurs.  In  a  few. 
cases  there  is  seen  a  constant  rhythmic  tremor  or  irregular  chorei- 
form movements  without  epilepsy.  As  will  be  mentioned,  those 
■cases  the  origin  of  which  is  marked  by  a  series  of  convulsions  are 
often  described  as  eclampsic  amentia,  whilst  those  in  which  the  fits 
continue,  and  have  the  characters  of  epilepsy,  are  spoken  of  as 
epileptic  amentia.  In  my  opinion,  however,  this  latter  term  should 
be  restricted  to  cases  of  amentia  due  to  idiopathic  epilepsy  without 
a  gross  lesion. 

Final  Lesions. — It  is  necessary  to  remember  that  in  course  of 
time  secondary  changes  take  place  in  and  around  the  initial  lesion, 
so  that  the  final  product  is  often  very  different  to  the  change  in  the 
first  instance,  and  it  is  then  usually  impossible  to  say  whether  the 
lesion  was  originally  vascular  or  toxic.  The  chief  ultimate  results, 
as  seen  in  post-mortem  examinations  made  many  years  afterwards, 
are  localized  areas  of  softening,  atrophy,  sclerosis,  heterotopia,  and 
agenesis;  cysts,  meningo-encephalitis,  porencephaly,  hemiatrophy, 
and  occasionally  hydrocephaly.  Sometimes  these  secondary 
dianges  give  rise  to  more  or  less  distinct  varieties,  which  may  be 
recognized  clinically,  and  these  will  be  described  in  subsequent 
pages. 


236     Secondary  Amentia  and  its  Clinical  Varieties 

Illustratr^  Cases. 

Medium-Grade  Amentia,  with  Hemiplegia  and  Convtdsions,  the 
Result  of  a  Birth  Ijij-ury. — M.  B.,  female.  No  family  histor}^ 
obtainable.  The  patient  has  had  fits  and  paralysis  since  a  baby, 
due  to  an  injury  at  birth.  She  went  to  school  for  a  few  years,  but 
could  never  learn.  At  twelve  years  of  age  was  admitted  into 
workhouse  in  consequence  of  death  of  parents.  Was  thence  sent 
into  the  asylum  owing  to  epileptic  fits.  She  is  now  twenty-two- 
years  of  age,  and  has  been  under  my  observation  for  two  years. 
She  is  a  placid,  simple-looking  girl  of  apparently  seventeen  years 
or  so,  rather  small,  but  well-nourished,  and  devoid  of  stigmata  of 
degeneracy.  There  is  left  hemiplegia  involving  the  leg,  arm, 
hand,  and  lower  part  of  the  face.  The  reflexes  are  exaggerated  on 
both  sides,  and  there  is  slight  lateral  nystagmus.  Xo  impairment 
of  sensation  can  be  made  ou.t.  She  is  subject  to  convulsive  attacks 
without  loss  of  consciousness,  the  duration  of  one  of  which  has 
been  as  long  as  two  hours.  These  consist  of  clonic  movements  of 
the  left  (paralyzed)  hand  and  arm,  with  twitching  of  the  left  comer 
of  the  mouth,  and  drawing  of  the  head  to  the  left  side.  During" 
the  attack  the  knee-jerks  are  exaggerated  (particularly  the  left), 
but  there  is  no  ankle  clonus,  and  the  pupils  are  normal.  She  says 
that  the  attacks  are  preceded  by  a  "  feeling  "  under  the  left  arm, 
and  that  whilst  they  last  she  feels  pins  and  needles  in  the  left  face, 
arm,  and  leg.  Some  of  these  attacks  are  followed  by  a  state  of 
general  rigidity,  with  loss  of  consciousness.  In  addition  she  has 
petit  mal  and  convulsions  which  are  t\^ically  epileptic.  Her  mental 
condition  is  that  of  a  high-grade  imbecile.  She  can  carry  on  a 
simple  conversation,  but  does  not  volunteer  information,  and  she 
will  agree  to  almost  anything  suggested  to  her.  She  cannot  read, 
but  can  just  scrawl  her  name.  She  can  count  up  to  thirty,  but 
cannot  say  what  two  and  two  make.  She  will  do  what  she  is  told, 
and  helps  in  the  ward-cleaning.  Her  memory  is  poor ;  she  has  no 
idea  of  time  or  dates,  but  her  attention  is  tolerably  good.  She 
is  occasionally  mischievous  and  takes  things  from  the  other  patients, 
but  on  the  whole  is  well-behaved  and  gives  little  trouble. 

Amentia  with  Double  Talipes  due  to  Asphyxia  Neonatorum. — 
M.  F.,  female.  There  is  nothing  abnormal  in  the  family  history. 
The  patient  is  the  fifth  of  a  family  of  ten ;  two  died  in  infancy,  the 
remainder  are  healthy.     The  mother  tells  me  that  M.  F.  was  a  very 


Plate  XV. 


To  face  pa^e  236.  ] 


Toxic,   Inflammatory  and  Vascular  Amentia     237 

large  child,  that  the  labour  was  very  prolonged,  and  that  she  was 
so  blue  and  lifeless  at  birth  that  the  doctor  in  attendance  had  to 
make  "  an  opening  in  her  throat."  I  do  not  know  what  this  could 
have  been,  and  can  find  no  evidence  (at  seventeen  years  of  age) 
of  any  tracheotomy  scar ;  but  there  seems  little  doubt  that  the  child 
had  severe  asphyxia  neonatorum.  The  mother  says  she  was  quite 
"  dummy  "  from  birth,  and  utterly  different  to  the  other  children; 
that  she  had  severe  fits  whilst  cutting  her  teeth,  did  not  walk  until 
four  and  a  half  years,  and  never  said  a  word  until  she  was  in  her 
sixth  j^ear.  She  went  to  school,  but  could  not  learn,  and  she  after- 
wards had  several  situations,  but  could  not  keep  them,  as  she  seemed 
too  simple  and  childish.  At  the  age  of  seventeen  years  she  began 
to  get  very  troublesome  and  spiteful;  she  was  considered  a  danger 
to  the  younger  children,  and  sent  to  the  asylum. 

Upon  admission  she  was  a  fairly  well-grown  girl,  with  a  decidedly 
childish  and  vacuous  expression.  There  was  no  observable  sensory 
defect.  She  could  understand  what  was  said  to  her,  and  was  capable 
of  replying  to  simple  questions.  She  could  read  and  write  words 
of  one  syllable,  and  could  add  up  to  ten.  On  the  whole  she  was 
quiet  and  well-behaved,  and  did  a  certain  amount  of  work  in  the 
laundry  under  supervision;  but  she  had  no  power  of  reasoning, 
and  was  obviously  far  too  deficient  to  earn  her  living.  She  was 
of  a  remarkably  facile  disposition,  and  readily  assented  to  any 
proposition  made  to  her ;  she  also  had  a  considerable  defect  in  the 
power  of  sustained  attention.  Speech  was  exceedingly  indistinct. 
She  had  double  talipes  varus,  with  some  dragging  of  the  feet  in 
walking,  but  no  other  signs  of  paresis.  She  is  now  nineteen  years 
of  age,  she  has  had  no  fits  since  childhood,  but  her  mental  deficiency 
is  becoming  more  marked.  She  is  at  times  rambling  and  incoherent 
in  her  conversation,  but  is  on  the  whole  well-behaved  and  gives 
no  trouble.  The  slight  paresis  of  the  feet  is  somewhat  more  pro- 
nounced than  formerly,  and  the  knee-jerks  are  exaggerated. 

Amentia  due  to  Trauma. — S.  V.,  female.  The  patient  is  the 
sixth  of  a  family  of  ten;  two  sisters  died  in  infancy,  but  the  re- 
mainder are  well  grown  and  quite  healthy  in  body  and  mind.  A 
complete  family  history  was  obtained,  and  revealed  an  entire 
absence  of  morbid  heredity.  S.  V.  was  born  at  full  term  without 
any  abnormal  circumstances.  She  cut  her  teeth,  walked,  and 
talked  at  the  ordinary  age,  and,  in  fact,  appeared  to  be  a  perfectly 
healthy  child  until  four  years  of  age.     She  then  had  a  fall  in  the 


238      Secondary  Amentia  and  its  Clinical  Varieties 

street,  striking  her  head  against  the  curb;  she  remained  uncon- 
scious for  half  an  hour,  and  then  came  to,  but  seemed  dazed.  Five 
weeks  afterwards  she  had  her  first  epileptic  fit,  and  they  have 
continued  almost  daily  since.  I  saw  her  for  the  first  time  at  the 
age  of  fourteen  years.  She  was  tolerably  well  grown  for  her  age, 
and  had  no  stigmata  of  degeneracy,  although  quite  idiotic  in  manner 
and  facies.  She  did  not  understand  all  that  was  said  to  her,  but 
could  obey  some  commands  by  signs.  She  was  incapable  of  any 
kind  of  work,  and  could  not  dress'  or  feed  without  help.  Con- 
stantly wet  and  dirty.  Could  say  a  few  monosyllabic  words,  but 
most  of  her  utterances  were  inarticulate  grunts.  She  was  said  to 
be  good-tempered  and  quite  harmless.  On  careful  examination, 
I  found  that  there  was  slight  dragging  with  eversion  of  the  right 
foot.  The  right  face  was  also  less  full  than  the  left,  but  there 
were  no  other  localizing  sxTnptoms.  The  fits  were  typically  epileptic, 
and  followed  by  a  prolonged  period  of  unconsciousness.  I  came  to 
the  conclusion  that  the  case  was  probably  one  of  combined  amentia 
and  dementia,  the  result  of  traumatic  epilepsy,  and  although  I 
thought  it  very  doubtful  whether  anything  could  be  done  so  long 
after  the  injury,  I  recommended  operation  as  a  justifiable  and  the 
only  possible  measure. 

Mild  Amentia,  with  Paralysis  and  Convulsions,  consequent  upon 
"Infantile  Hemiplegia." — F.  D.  W.,  male.  Xo  morbid  heredity. 
His  brothers  and  sisters  are  healthy  in  body  and  mind,  and  the 
patient  appeared  perfectly  normal  until  his  second  year.  He 
then  had  a  severe  illness,  which  left  him  paralyzed  in  the  right 
hand  and  arm,  and  a  few  years  later  he  was  noticed  to  be  more 
simple  than  other  children  of  his  age.  He  went  to  school,  but 
could  never  get  on,  and  he  cannot  read,  write,  or  sum.  Upon 
leaving  school  he  used  to  help  his  father  (who  is  a  publican)  in  the 
bar,  but  he  has  never  followed  any  regular  employment.  He  was 
subject  to  occasional  epileptic  fits,  and  after  one  of  these  assaulted 
his  father  and  sister,  and  became  so  unmanageable  generally  that 
he  had  to  be  sent  to  an  asylum,  where  he  has  since  remained.  He 
is  now  forty-two  years  of  age,  and  is  a  well-developed  man  of 
medium  height,  with  no  stigmata  of  degeneracy.  His  facial  ex- 
pression is  placid  and  somewhat  childish.  There  is  dropping  of 
the  right  wrist,  and  the  interossei  as  well  as  the  muscles  of  the 
thenar  and  h\-pothenar  eminences  and  forearm  are  very  little 
developed.     The  whole  of  the  right  forearm  is  short  and  stunted, 


Plate  XVI. 


To /ace  page  238.]. 


Toxic,   Inflammatory  and  Vascular  Amentia     239 

as  compared  with  the  left.  He  can  make  use  of  the  affected  arm 
for  coarse  purposes,  but  he  cannot  perform  fine  movements.  He 
cannot  move  the  toes  of  the  right  foot,  and  they  are  cold  and  blue, 
but  there  is  no  other  observable  paralysis  of  this  or  any  other 
portion  of  the  body.  There  is  no  sensory  defect,  and  he  has  had  no 
fits  for  several  years.  His  memory  is  only  fair,  and  is  better  for 
remote  than  recent  events.  His  power  of  attention  is  good,  and 
he  has  no  special  sense  defect.  He  can  carry  on  a  simple  con- 
versation, and  can  give  a  tolerably  good  account  of  his  past  life; 
but  his  general  intelligence  is  poor,  and  he  is  too  childish  to  take 
care  of  himself  without  supervision.  He  is  very  suspicious  of 
strangers,  and  very  disinclined  to  answer  their  questions.  He  is 
emotional,  and  readily  moved  to  laughter  or  tears.  He  is  very 
variable  in  temper,  and  at  times  surly,  perverse,  and  very  trouble- 
some, but  at  others  he  is  a  not  unwilling  worker  in  the  dormitories. 
(See  Plate  XVI.,  Fig.  41.) 

Mild  Amentia  with  Paraplegia,  due  to  a  Cerebral  Lesion  during 
Birth. — T.  W.,  male,  aged  thirty-three  years.  Owing  to  the  death 
of  the  patient's  parents  a  complete  history  is  unobtainable,  but, 
as  far  as  can  be  ascertained,  there  is  no  morbid  heredity,  and  the 
condition  is  the  result  of  a  lesion  during  birth,  which  left  the 
patient  paralyzed  in  both  legs  and  mentally  defective.  He  has 
been  in  institutions  since  childhood,  and  although  he  has  learned 
to  read  and  write  fairly  well,  and  even  to  do  simple  sums  in  arith- 
metic, the  absence  of  any  systematic  manual  training,  together 
with  his  general  intractability,  causes  him  to  be  quite  unemployed. 
He  has  an  alert,  and  at  times  a  decidedly  cunning,  look,  and  his 
features  are  of  a  low  animal  type,  but  there  are  no  pronounced 
stigmata  of  degeneracy.  The  skull  is  symmetrical  and  larger  than 
usual,  the  circumference  being  23  inches.  Both  lower  limbs  are 
completely  paralyzed  from  the  thighs  downwards;  they  are  also 
very  small  and  imperfectly  developed,  blue  and  cold,  and  covered 
with  a  plentiful  growth  of  hair.  Tactile  sensation  is  markedly 
diminished  in  the  paralyzed  limbs,  and  the  knee-jerks  and  plantar 
reflexes  are  absent.  Walking  is  impossible,  but  the  patient  is  very 
adept  at  propelling  himself  along  on  his  haunches  by  making  use  of 
his  hands  and  arms  as  levers.  There  have  never  been  any  con- 
vulsions. There  is  no  defect  of  the  special  senses.  He  understands 
most  of  what  is  said  to  him,  and  can  reply,  but  usually  refuses  to 
do  so.     His  memory  is  good;  he  is  very  observ^ant,  and  capable 


240     Secondary  Amentia  and  its  Clinical  Varieties 

of  simple  reasoning;  but  he  cannot  follow  an  argument,  and  his 
ideas  and  general  behaviour  are  characterized  by  a  childish  sim- 
plicity. The  powers  of  attention  and  control  are  markedly  defec- 
tive. If  asked  to  write  his  name,  he  takes  the  pencil  in  his  hand, 
looks  at  it,  and  then  puts  it  down  to  look  at  his  arm.  He  then 
takes  it  up  again  and  makes  a  start,  but  drops  it  to  scratch  his  back. 
Another  beginning  is  interrupted  to  look  at  someone  coming  in 
at  the  door.  In  fact,  he  is  as  inquisitive  and  curious  as  a  monkey, 
and  so  distracted  by  everything  happening  around  him  that  he 
can  settle  down  to  nothing.  He  is  destructive  and  constantly 
tears  up  his  clothes,  and  from  time  to  time  he  has  outbreaks  of 
noisy  violence,  during  which  he  uses  disgusting  language  and 
attacks  anyone  who  may  be  near  him.     (See  Plate  XVI. ,  Fig.  42.) 

Amentia  with  Epilepsy,  due  to  "  Sunstroke." — E.  S.,  male.  The 
eighth  born  of  a  family  of  nine,  all  the  others  being  healthy.  There 
is  a  tendency  to  alcoholism  on  the  parental  side,  but  no  insanity, 
epilepsy,  or  consumption.  The  patient  seemed  perfectly  well  until 
three  years  of  age.  Dentition  had  been  normal;  he  was  able  to 
walk  well,  and  was  making  progress  with  his  talking.  When  just 
turned  three  he  had  "  what  the  doctor  called  meningitis  "  following 
exposure  to  a  severe  sun.  The  mother  says  that  for  nine  weeks 
he  was  unconscious  and  repeatedly  convulsed.  For  twelve  months 
after  this  he  never  uttered  a  S5^11able ;  he  then  began  to  pick  up  a 
few  words  again,  but  made  little  progress,  and  his  parents  noticed 
a  profound  change  in  him.  Usually  he  was  dull  and  stupid,  and 
seemed  to  have  little  sense,  but  at  times  he  became  violent,  and 
unmanageable.  The  fits  continued  at  short  intervals,  and  at  the 
age  of  nine  he  became  so  troublesome  that  he  had  to  be  sent  to 
the  asylum.  On  admission  he  was  somewhat  undersized  for  his 
age,  and  poorly  nourished.  His  features  were  good,  and  there  were 
no  stigmata  of  degeneracy,  but  the  expression  was  vacant.  Fits 
occurred  daily;  they  were  very  severe,  preceded  by  cry,  followed 
by  a  period  of  unconsciousness,  and  had  all  the  characteristics  of 
true  epilepsy.  He  could  understand  what  was  said  to  him,  and 
would  occasionally  reply,  but  as  a  rule  he  was  moody  and  silent, 
and  resented  being  questioned.  He  was  incapable  of  any  employ- 
ment. The  patient  steadily  became  worse.  He  was  a  confirmed 
masturbator  and  addicted  to  swallowing  pebbles.  He  became  wet 
and  dirty,  required  to  be  fed,  and  needed  constant  attention.  He 
took  no  notice  of  his  surroundings,  did  not  seem  to  understand  what 


Plate  XVII. 


To  /ace  page  240.] 


Toxic,  Inflammatory  and  Vascular  Amentia     241 

he  was  told,  and  if  examined  became  very  resistant  and  forbidding. 
At  times  he  would  sit  in  a  chair  flapping  his  arms  and  making 
hideous  noises;  at  others  he  was  moodily  silent.  He  died,  at  the 
age  of  seventeen  years,  of  exhaustion  after  a  series  of  fits. 

On  making  a  post-mortem  examination,  I  found  the  skull  very 
thick  and  dense,  the  diploe  being  obliterated.  The  brain  was 
small,  and  weighed  37^  ounces,  the  left  hemisphere  being  5|  ounces 
less  in  weight  than  the  right.  The  ventricles  were  dilated,  and 
there  was  considerable  excess  of  clear  fluid.  The  membranes 
appeared  normal.  The  brain  was  tolerably  well  convoluted,  and 
presented  nothing  abnormal  externally,  beyond  a  general  diminu- 
tion of  size.  On  making  careful  sections,  however,  a  localized  area 
of  softening,  about  the  size  of  a  filbert,  was  found  in  the  left  supra- 
marginal  convolution  at  the  junction  of  the  grey  and  white  matters. 
This  in  all  probability  was  of  vascular  origin,  and  the  final  result 
of  the  attack  of  encephalitis  which  took  place  at  three  years  of 
age.     (See  Plate  XVII. ,  Fig.  43.) 

Mild  Amentia  with  Motor  Aphasia,  due  to  an  Infantile  Cerebral 
Lesion. — N.  T.,  male,  born  in  India,  the  second  child  of  a  family 
of  six.  Parents  healthy,  and  no  morbid  heredity.  Seemed  per- 
fectly normal  until  nine  months  old,  when  he  had  a  series  of  con- 
vulsions lasting  three  days.  These  continued,  at  intervals  of  a 
few  months,  until  he  was  three  years  of  age;  they  were  attended 
with  unconsciousness,  and  in  the  last  attack  he  was  given  up  by 
the  doctor.  He  recovered,  however,  and  has  had  no  further  fits; 
but  from  that  time  his  parents  noticed  a  great  mental  change. 
He  failed  to  understand  what  was  said  to  him,  became  restless  at 
night,  exceedingly  dirty  in  his  habits,  and  required  constant  watch- 
ing during  the  day  to  prevent  him  destroying  everything  he  could 
lay  his  hands  on.  As  time  passed  some  improvement  took  place ; 
he  became  more  manageable,  and  able  to  do  little  things  for  him- 
self. He  would  also  help  his  mother  in  laying  the  dinner-table  and 
similar  household  duties,  but  he  could  not  be  depended  upon,  was 
at  times  very  intractable,  and  was  quite  unable  to  speak. 

I  first  saw  him  at  the  age  of  eleven  years.  He  was  a  sturdy,  well- 
developed  boy,  with  good  features  but  a  decidedly  vacuous  ex- 
pression. There  was  no  sensory  defect;  he  could  understand 
simple  commands  and  remarks;  but  he  was  obstinate,  and  took 
little  notice  of  anything  said  to  him.  He  could  whistle,  but  could 
not  articulate,  and  he  was  passionate  and  untrustworthy.     As  far 

16 


242     Secondary  Amentia  and  its  Clinical  Varieties 

as  could  be  ascertained  in  the  absence  of  conversation,  his  general 
intelligence  was  about  equal  to  that  of  a  normal  child  of  five  or 
six  years.  I  came  to  the  conclusion  that  the  case  was  one  of  mild 
amentia  caused  by  meningo-encephalitis  or  some  toxic  process 
involving  the  motor  speech  centre,  and  considered  the  prospect 
of  improvement  slight,  but  recommended  special  training  in  an 
institution.  This  has  now  been  carried  out  for  three  years.  He 
has  improved  greatly  in  habits  and  general  behaviour;  he  is  now 
thoroughly  obedient  and  dependable,  and  evinces  an  affectionate 
disposition  towards  those  about  him.  He  is  fond  of  manual  work, 
and  can  perform  many  kindergarten  occupations,  such  as  plaiting 
and  bead-threading,  very  well.  He  lays  the  dinner-plates  with  a 
marvellous  dexterity.  He  has  learned  to  make  pot-hooks  and 
hangers,  knows  some  of  his  letters,  and  can  count  up  to  six.  But 
he  finds  school-work  very  uncongenial,  and  cannot  settle  down 
to  it.  He  seems  incapable  of  making  any  mental  effort.  He 
understands  all  that  is  said  to  him,  but  still  remains  unable  to 
articulate,  and,  in  spite  of  persistent  attempts  to  teach  him,  the 
nearest  approach  to  a  word  he  can  utter  is  a  guttural  "  cuckoo." 

Mild  Amentia  consequent  on  "  Meningitis  "  at  Fifteen  Months  of 
Age. — K.  G.,  male.  Was  born  in  India,  and  has  four  brothers  and 
sisters  alive  and  well.  His  mother  is  an  exceedingly  delicate, 
neurotic  woman,  his  father  strongly  addicted  to  alcohol ;  but  there 
is  no  history  of  epilepsy  or  insanity  on  either  side.  The  patient 
seemed  all  right  until  fifteen  months  old,  when  he  was  laid  up  for 
two  months  with  some  brain  illness,  accompanied  by  fits,  which  is- 
described  as  "  meningitis."  From  this  time  he  became  subject 
to  fits  of  irritability,  and  showed  indications  of  mental  defect.  He 
went  to  school  at  the  age  of  seven,  and  showed  a  considerable  taste 
for  drawing  and  manual  work;  but  he  was  never  able  to  make 
progress  in  any  studies,  and  seemed  incapable  of  mental  applica- 
tion. I  saw  him  in  consultation  at  the  age  of  eleven ;  he  could  then 
read  and  write  simple  sentences,  and  was  capable  of  simple  addition 
and  subtraction  sums.  He  had  a  good  memory,  and  could  recount 
a  few  historical  and  geographical  facts,  but  his  manner  was  very 
restless  and  his  attention  very  fitful;  he  was  quite  incapable  of 
settling  down  to  school-work,  and  his  general  intelligence  and  power 
of  reasoning  were  no  greater  than  those  of  a  normal  child  of  six 
years.  Cranial  circumference,  2 if  inches.  He  was  affectionately 
disposed  to  those  about  him,  but  of  a  very  undependable  temper.. 


Toxic,  Inflammatory  and  Vascular  Amentia     243 

Was  addicted  to  hiding  up  trifling  objects  of  no  value,  and  had 
wandered  away  from  home  on  several  occasions.  At  times  he 
was  destructive,  and  would  tear  up  clothes,  toys,  and  picture- 
books  indiscriminately.  Occasionally  he  was  noisy  and  aggres- 
sive, and  had  attacked  those  about  him.  He  improved  very  con- 
siderably under  special  training,  and  there  seems  every  probability 
of  his  being  able  to  follow  an  occupation  under  supervision. 

Amentia  accompanied  by  Porencephaly  or  Cerebral  Hemiatrophy. — 
As  seen  in  the  post-mortem  room,  these  cases  appear  to  be  widely 
different  from  those  just  described,  in  which  the  pathological 
findings  are  cysts,  localized  atrophies,  softening,  meningo-enceph- 
alitis,  and  the  like.  Here  we  have  to  do  with  a  condition  of 
porencephaly  or  hemiatrophy  of  such  an  extent  that  the  affected 
hemisphere  may  be  200  or  300,  or  even  more,  grammes  less  in 
weight  than  the  opposite  one,  and  it  would  seem  as  if  such  must 
be  accompanied  by  special  clinical  features.  In  some  instances 
this  is  so,  and  on  that  account  it  is  desirable  to  refer  to  these  con- 
ditions separately.  But,  on  the  other  hand,  it  must  be  admitted 
that  these  severe  conditions  can  often  only  be  suspected  during  life, 
and  that  they  are  by  no  means  rarely  found  after  death  when 
there  had  previously  been  nothing  to  suggest  that  more  than  a 
minor  pathological  disturbance  was  present.  An  interesting  case 
of  this  nature  has  been  recorded  by  Conolly  Norman  and  Fraser.* 
It  was  that  of  a  very  fine  female  who  had  never  been  under  restraint, 
and  who  presented  no  external  evidence  of  extensive  brain  disease 
in  the  shape  of  atrophy,  contractures,  etc.,  and  yet  post-mortem 
there  was  found  extreme  wasting  of  one  hemisphere,  as  well  as 
of  the  corresponding  basal  ganglia.  Many  similar  cases  in  which 
the  clinical  signs  have  been  comparatively  slight  have  been  re- 
corded by  other  writers — viz..  Van  der  Kolk,  Bianchi,  Heschl, 
Spiller,  Lambl,  etc. 

In  most  cases  these  conditions  are  the  result  of  disease,  and 
date  from  very  early  infancy,  if  not  from  uterine  existence ;  a  few, 
however,  seem  to  be  due  to  primary  anomalies  of  development. 
But  the  distinction  can  only  be  inferred  clinically,  and  not  always 
made  with  certainty  upon  dissection. 

During  life  an  ament  may  be  suspected  to  be  the  subject  of 
porencephaly  or  extensive  hemiatrophy  if  there  is  severe  hemi- 

*  Conolly  Norman  and  Alec  Fraser,  "  A  Case  of  Porencephaly,"  Journal  of 
Menial  Science,  October,  1S94. 


244     Secondary  Amentia  and  its  Clinical  Varieties 

plegia  accompanied  by  contractures  and  marked  non-develop- 
ment of  the  affected  limbs,  and  if  convulsions  are  also  present. 
But,  as  already  remarked,  the  hemiplegia,  in  some  cases  of  pro- 
nounced porencephaly  discovered  post-mortem,  is  often  astonish- 
ingly insignificant,  and  it  rarely  involves  the  tongue  or  face.  The 
convulsions  are  of  the  usual  epileptic  type,  and  are  fairly  frequent, 
but  cases  have  been  recorded  in  which  they  were  absent.  Some- 
times much  headache  is  complained  of.  The  diagnosis  is  rendered 
more  probable  if,  in  addition,  there  is  marked  flattening  of  one 
side  of  the  skull,  but  in  many  of  these  cases  the  space  is  filled  up  by 
excess  of  fluid  or  growth  of  the  inner  table,  so  that  the  external 
conformation  of  the  skull  is  not  altered.  I  know  of  no  other 
distinguishing  features.  The  amentia  may  be  of  any  grade,  from 
a  mild  imbecility  to  gross  idiocy,  and  stigmata  of  degeneracy  may 
be  present  or  absent  according  as  the  case  is  one  of  primary  amentia 
complicated  by  these  lesions,  or  one  of  secondary  amentia  due 
to  them.  In  the  latter  dementia  often  supervenes,  and  death 
frequently  results  from  tuberculosis  or  follows  a  succession  of  fits. 
Of  Kundrat's*  series  of  eighteeen  cases  of  porencephaly,  only  three 
survived  the  period  of  infancy. 

Illustrative  Cases. 

False  Porencephaly  with  Cystic  Formation. — A.  E.  TF.,|  female. 
Imbecile.  No  morbid  inheritance.  Born  paralyzed  on  right  side. 
Constantly  suffered  from  headache  and  epileptic  fits.  The  paralysis 
involved  the  right  arm  and  leg,  but  not  the  face.  The  affected 
limbs  were  smaller  and  shorter  than  the  sound  ones.  There  was 
talipes  equino-varus  of  the  right  foot,  but  no  contractures.  The 
knee-jerks  were  absent.  Speech  indistinct,  memory  poor,  depressed 
and  dull  mentally.  She  was  subject  to  frequent  fits,  beginning 
in  the  affected  side,  and  then  becoming  general.  She  gradually 
became  more  and  more  demented,  and  died  at  the  age  of  twenty- 
two,  after  a  succession  of  severe  fits. 

The  post-mortem  examination  showed  extensive  atrophy  of 
the  lower  part  of  the  motor  region  on  the  left  side,  and  of  the 
corresponding  efferent  tract  in  the  pons,  medulla,  and  cord.     The 

*   Kundrat,  "  Die  Porencephalie,"  Gratz,  1S82. 

f  For  a  fuller  description  of  the  histological  appearances  in  this  and  the 
follomng  case,  see  "  Hemiatrophy  of  the  Brain,"  by  INIott  and  Tredgold, 
Brain,  part  xc,  1900. 


Toxic,  Inflammatory  and  Vascular  Amentia     245 

depression  in  the  brain  was  occupied  by  a  subarachnoid  cyst.  The 
left  ventricle  also  was  greatly  dilated.  The  weight  of  the  left 
hemisphere  was  435  grammes,  and  of  the  right  585  grammes. 

Cerebral  Hemiatrophy  with  Ventricular  Dilatation. — /.  E.,  male. 
Fits,  paresis  of  right  arm,  and  weak-mindedness  from  infancy. 
The  right  leg  also  weak,  but  he  was  able  to  walk,  and  he  had  been 
engaged  as  a  shoeblack.  He  was  admitted  into  the  asylum  at  the 
age  of  twenty-six  in  consequence  of  frequent  epileptic  fits  accom- 
panied by  attacks  of  noisy  excitement.  On  several  occasions  he 
had  attacked  those  about  him  without  provocation.  He  gradually 
became  demented,  and  died,  aged  thirty,  of  acute  phthisis. 

On  post-mortem  examination  the  skull  was  symmetrical  ex- 
ternally, but  there  was  marked  thickening  of  the  whole  of  the  inner 
table  on  the  left  side.  In  some  situations  the  thickness  was  more 
than  twice  that  of  the  opposite  side.  The  weight  of  the  right 
hemisphere  was  575  grammes,  that  of  the  left  but  155  grammes. 
The  left  ventricle  was  hugely  dilated,  the  substance  of  the  hemi- 
sphere being  reduced  to  a  mere  shell  in  places.  The  left  basal 
ganglia,  particularly  the  optic  thalamus,  were  also  exceedingly 
small  and  ill-developed.  There  was  consecutive  atrophy  of  the 
left  crus,  pyramid  and  fillet  in  the  pons  and  medulla,  with  atrophy 
of  the  right  half  of  the  cerebellum  and  its  superior  peduncle.  There 
was  also  sclerosis  of  the  left  direct  and  right  crossed  pyramidal 
tracts  in  the  cord,  of  the  left  antero-lateral  column,  and  marked 
numerical  diminution  of  the  anterior  horn  cells  in  the  cervical  and 
lumbar  regions. 

The  following  description,  by  Dr.  Ross,  of  a  case  of  double  true 
porencephaly  (which  is  exceedingly  rare)  is  quoted  by  Ireland: 

"  The  patient  was  a  little  girl  who  died  of  croup  at  the  age  of 
two  years  and  five  months.  At  the  age  of  three  months  her  parents 
first  observed  that  she  could  not  hold  her  head  up,  and  that  her 
hands  were  stiff.  She  never  at  any  time  suffered  from  convulsions. 
The  child  was  small  for  her  age,  but  fairly  nourished.  The  legs 
were  kept  in  a  half-flexed  condition,  the  feet  extended,  and  the 
heels  drawn  up.  The  arms  were  held  semiflexed  in  a  symmetrical 
position.  The  muscles  of  both  extremities  were  in  a  state  of 
spasmodic  rigidity.  Any  attempt  to  alter  by  passive  motion  the 
position  of  the  limbs  caused  increased  spasmodic  contractions. 
The  head  was  kept  bent  forwards,  the  chin  upon  the  sternum ;  but 
she  could  raise  her  head  by  an  effort,  soon  again  to  fall  into  the 


246     Secondary  Amentia  and  its  Clinical  Varieties 

old  posture.  She  could  voluntarily  grasp  an  object  with  each 
hand,  but  the  movements  were  irregular  and  uncertain.  She 
could  only  utter  a  few  monosyllables." 

"  On  examination  after  death,  a  deep  sulcus  was  found  in  each 
side  of  the  brain,  about  the  site  of  the  fissure  of  Rolando,  extend- 
ing from  the  point  of  bifurcation  of  the  Sylvian  fissure  for  about 
1 1  inches  upwards.  Each  sulcus  opened  into  the  corresponding 
lateral  ventricle  by  an  aperture  the  size  of  the  little  finger.  Each 
opening  was  surrounded  by  a  ring  of  grey  matter  having  all  the 
naked-eye  appearances  of  the  cortex.  The  ascending  frontal  and 
ascending  parietal  appeared  to  be  absent,  and  the  surrounding 
gyri  were  displaced.  The  crura  cerebri,  pons  and  medulla  appeared 
quite  normal  to  the  naked  eye. ' '  Microscopical  examination  showed 
that  the  cortex  contained  a  number  of  imperfectly  developed  cells 
almost  destitute  of  processes.  The  anterior  pyramids  of  the 
medulla  also  were  not  more  than  half  the  size  of  those  of  a  normal 
child  of  corresponding  age,  and  the  lateral  columns  of  the  cord 
were  also  diminished  in  size. 

Bourneville*  has  recorded  six  cases  of  cerebral  hemiatrophy,  of 
which  the  following  are  synopses.  All  the  patients  were  imbeciles 
or  idiots,  and  almost  all  suffered  from  epileptic  convulsions  and 
showed  post-mortem  sclerosis,  atrophy,  and  chronic  changes  in 
the  membranes  and  brain  tissue. 

1.  Pseudo-porencephaly.  Fifteen  years  old.  Left  hemiplegia 
with  epilepsy.  Right  hemisphere,  240  grammes.  Left  hemi- 
sphere, 560  grammes. 

2.  Imbecile.  Twenty-one  years.  Right  hemiplegia  and  epilepsy. 
Right  hemisphere,  465  grammes.     Left  hemisphere,  185  grammes. 

3.  Imbecile.  Eleven  years.  Left  hemiplegia  and  epilepsy. 
Left  hemisphere,  570  grammes.  Right  hemisphere,  310  grammes, 
showing  pachymeningitis  and  meningo-encephalitis. 

4.  Idiot.  Four  and  a  half  years.  Right  hemisphere,  460 
grammes.     Left  hemisphere,  200  grammes,  with  marked  sclerosis. 

5.  Imbecile.  Thirteen  years.  Right  hemiplegia.  Right  hemi- 
sphere, 665  grammes.     Left  hemisphere,  455  grammes. 

6.  Idiot.  Ten  years.  Right  hemisphere,  477  grammes.  Left 
hemisphere,  255  grammes. 

*   Bourneville,  Progrds  Midical,  1S98,  p.  248. 


Sclerotic  Amentia  247 


SCLEROTIC  AMENTIA. 

It  has  already  been  remarked  that  sclerosis,  due  to  proliferation 
of  neuroglia,  is  found  post-mortem  in  a  considerable  number  of 
cases  of  both  the  primary  and  secondary  forms  of  amentia.*  In 
many  of  these  it  is  a  pathological  condition  which  has  no  clinical 
significance,  and  it  gives  rise  to  no  definite  symptoms  by  which  its 
presence  may  be  diagnosed,  or  even  suspected,  during  life.  In  a 
small  proportion  of  cases,  however,  the  neurogliosis  attains  such 
magnitude  as  to  produce  a  tolerably  readily  recognizable  type  of 
amentia,  and  this  we  shall  here  describe. 

Regarding  the  etiology  of  these  cases  our  knowledge  is  very 
imperfect,  and  it  is  probable  that  a  similar  result  may  be  produced 
by  different  causes.  In  many — indeed,  I  think,  in  the  majority 
of  cases — inquiries  into  the  family  history  reveal  the  presence  of 
alcoholism,  phthisis,  insane  and  epileptic  heredity,  precisely  the 
same  as  in  ordinary  cases  of  primary  amentia;  but  in  addition 
there  is  often  a  history  of  birth  injury  or  other  vascular  or  toxic 
lesion  of  early  infancy  which  may  possibly  act  as  a  determining 
factor;  whilst  in  a  few  cases  the  latter  conditions  alone  are  present. 
But  although  it  seems  probable  that  in  the  majority  of  cases 
sclerosis  is  determined  by,  and  is  the  after-effect  of,  some  diseased 
(vascular  or  toxic)  condition  of  the  brain,  there  is  no  doubt  that  in 
a  small  number  of  instances  it  may  arise  independently  of  such  con- 
ditions, and  it  is  then  to  be  regarded  as  a  developmental  anomaly 
complicating  primary  amentia.  But  whether  the  amentia  be  a 
primary  one  complicated  by  sclerosis,  or  whether  the  sclerosis  is 
itself  the  cause  of  the  amentia,  the  result  is  pretty  much  the  same, 
and  since  the  special  clinical  symptoms  in  these  cases  are  in  the 
main  referable  to  the  sclerosis,  and  since,  moreover,  the  cases 
resemble  many  of  the  pure  secondary  forms  in  their  tendency  to 
degeneration  and  dementia,  it  seems,  on  the  whole,  preferable  to 
describe  sclerotic  amentia  in  this  place. 

There  are  two  chief  types  of  sclerosis,  dependent  upon  whether . 
the  proliferation  of  neuroglia  is  generally  dijfused  throughout  the 
cortex,  or  occurs  in  circumscribed  patches.     This  division,  perhaps, 
is  not  an  absolute  one,  for  cases  occur  in  which  both  a  diffuse  and 
circumscribed  gliosis  exist,  and  cases  of  diffuse  sclerosis  have  been 

*   See  Chapter  IV.,  Pathology,  p.  79. 


248     Secondary  Amentia  and  its  Clinical  Varieties 

described  which  were  localized  to  one  hemisphere.  On  the  whole, 
however,  the  majority  of  cases  conform  to  one  or  other  type,  and 
these  types  are  accompanied  by  different  clinical  symptoms. 
Briefly,  it  may  be  said  that  in  cases  of  diffuse  sclerosis  the  dominating 
symptoms  are  general  muscular  weakness,  often  accompanied  by 
spastic  rigidity  and  feeble  contractures,  but  rarely  by  actual 
paralysis.  There  is  also  marked  tremor,  but  not  often  definite 
convulsions.  In  localized,  nodular,  or  tuberous  sclerosis,  on  the 
other  hand,  there  are  usually  frequent  epileptic  fits  without  paralysis 
or  contractures,  although  movements  are  often  tottering  and 
tremulous,  and  in  these  latter  cases  death  often  results  from  a 
succession  of  fits. 

Diffuse  Sclerosis. 

Rapidly  increasing  gliosis  produces  an  enlargement  of  the  brain, 
and  in  this  way  gives  rise  to  a  clinical  variety  of  amentia  which 
is  known  as  "  hypertrophic."  With  the  lapse  of  time,  however, 
the  neuroglia  tends  to  contract,  and  there  is  then  produced  a 
regular  or  irregular  form  of  brain  atrophy.  The  hypertrophic  brain 
never  tends  to  indefinite  enlargement  as  does  the  hydrocephalic, 
and  contraction  is  only  a  question  of  time.  This  contraction  of 
the  glia  tissue  is  well  seen  in  the  central  umbilication  which  takes 
place  in  the  tuberous  areas  of  the  localized  form;  it  may  also  be 
observed  in  other  diseases;  for  instance,  the  spinal  cord  in  the 
early  stage  of  extensive  disseminated  sclerosis  is  greatly  swollen, 
whilst  in  the  later  stages  it  becomes  exceedingly  small,  shrivelled, 
and  distorted. 

Dependent  upon  whether  cranial  enlargement  is  or  is  not  a 
prominent  feature  we  may  divide  cases  of  diffuse  sclerosis  into  two 
groups — namely,  atrophic  and  hypertrophic  forms.  But,  as  already 
stated,  it  is  doubtful  whether  there  is  any  essential  pathological 
difference  between  these  two  forms,  and  the  clinical  difference  is 
probably  dependent  upon  the  extent  and  rapidity  with  which 
neuroglial  increase  takes  place  whilst  the  cranial  bones  are  yet 
ununited.  Where  synostosis  has  not  occurred,  so  that  expansion 
of  the  skull  may  allow  of  cerebral  enlargement,  the  prognosis  as 
to  life  and  response  to  training  is  much  more  favourable  than  where 
the  bones  offer  an  unyielding  resistance. 

{a)  Atrophic  Form. — These  cases  are  very  rare.  In  those  hitherto 
recorded  the  mental  deficiency  has  usually  been  of  a  pronounced 


Diffuse  Sclerosis  249 

grade,  and  although  there  may  be  some  slight  response  to  training 
at  first,  progressive  dementia  supervenes  sooner  or  later.  Definite 
convulsions  are  uncommon,  but  a  condition  of  muscular  tremor  is 
always  present.  This  varies  from  a  more  or  less  constant  shaking 
of  the  head  to  an  incessantly  repeated  fine  tremor  of  the  whole 
body.  It  is  increased  under  observation  or  voluntary  effort,  and 
is  often  described  as  chorea;  but  it  is  more  akin  to  the  tremor  of 
paralysis  agitans.  In  addition  there  is  a  general  muscular  weak- 
ness, with  spasm  and  incomplete  contractures  of  the  arms  or  legs, 
but  there  is  rarely  actual  paralysis.  The  reflexes  are  increased. 
In  some  cases  both  epileptic  convulsions  and  paralysis  are  present, 
and  BourneviUe*  has  described  a  case  in  which  these  were  at  first 
limited  to  one  side  of  the  body;  but  at  the  age  of  thirteen  classic 
epilepsy  appeared,  and  the  patient  died,  aged  twenty-one,  in  status 
epilepticus.  The  post-mortem  examination  showed  atrophy  and 
sclerosis  of  the  whole  of  one  hemisphere. 

Illustrative  Cases. 

Diffuse  Sclerotic  Amentia  with  Progressive  Dementia.^ — E.  G., 
female,  was  admitted  to  Darenth  Asylum  at  the  age  of  twelve 
years.  No  history  obtainable.  Her  mental  status  wa:-  that  of 
an  imbecile,  but  sight  and  hearing  were  good,  and  she  possessed 
a  good  memory  for  faces.  Speech  was  very  scanty,  and  was  slow 
and  hesitating.  Habits  cleanly.  She  was  described  as  a  cripple, 
but  not  paralyzed.  There  was  general  muscular  weakness  of  all 
the  limbs,  so  that  she  was  unable  to  wash,  dress,  feed,  or  do  any- 
thing for  herself.  In  addition  there  was  a  slight  shaking  move- 
ment of  the  head.  She  spent  all  her  time  sitting  in  a  chair,  but 
she  noticed  what  went  on  round  her.  The  cranial  circumference 
was  19I  inches. 

After  a  time  the  shaking  movements  of  the  head  increased,  and 
eventually  extended  to  all  the  limbs.  There  were,  however,  never 
any  definite  convulsions.  The  muscular  helplessness  also  increased, 
and  the  arms  and  legs  became  slightly  contracted  at  the  elbows 
and  knees  respectively.  She  became  duller  mentally,  less  ob- 
servant, and  wet  and  dirty  in  her  habits.     Finally  her  temperature 

*  Bourneville,  "  Sclerose  Cerebrale  HemispMrique,"  Archives  de  Neuro- 
logie,\i&gj,  vol.  iii. 

t  For  the  clinical  notes  of  this  case  I  am  indebted  to  Dr.  F.  R.  P.  Taylor, 
formerly  Medical  Superintendent  of  Darenth  Asylum. 


250     Secondary  Amentia  and  its  Clinical  Varieties 

suddenly  ran  up  to  104°  F.,  and  her  pulse  to  180,  and  she  gradually 
sank  and  died  without  any  signs  of  disease  other  than  the  cerebral 
sclerosis.     Her  age  at  death  was  twenty  years. 

Post-mortem  examination  failed  to  reveal  disease  of  any  organ 
other  than  the  brain.  The  dura  mater  was  thick  and  congested; 
the  pia  thick  and  opaque,  but  non-adherent.  The  whole  brain 
was  small,  but  heavy  for  its  size,  weighing  32  ounces.  Its  con- 
sistence was  extremely  dense — in  fact,  almost  like  cartilage.  Upon 
making  a  microscopical  examination  I  found  that  the  whole  of 
the  hemispheres,  the  white  as  well  as  the  grey  matter,  were  the 
site  of  a  dense  diffuse  sclerosis;  the  cerebellum  was  similarly 
involved. 

The  following  very  similar  case  is  described  by  Dr.  0.  Heubner:* 

The  patient,  a  boy  of  five  years,  seemed  bodily  and  mentally 
sound  until  the  age  of  three  and  a  half  years,  except  that  he  was 
late  in  learning  to  speak,  and  could  not  talk  fluently.  The  family 
was  said  to  be  healthy.  Apparently  as  the  result  of,  or  at  any 
rate  after,  a  fall  on  the  back  of  the  head,  he  no  longer  played 
willingly,  and  was  often  apathetic.  Nine  months  afterwards 
appeared  a  slothfulness  of  all  movement,  and  his  walk  became 
staggering.  This  was  followed  by  spastic  paralysis  of  the  legs, 
with  contractures  of  the  hips  and  knees,  and  double  equino-varus. 
Strong  intention  tremors  then  appeared  in  the  arms,  also  followed 
by  spastic  paralysis.  There  was  difficulty  in  swallowing,  so  that 
he  could  only  take  liquids,  and  eventually  be  became  unable  to 
speak.  There  was  constant  movement  of  the  head  and  upper 
extremities,  and  there  was  slight  paresis  of  the  lower  part  of  the 
right  face.  He  became  progressively  weaker  in  mind,  but  able  to 
recognize  people  he  knew,  and  there  was  no  observable  alteration 
in  general  or  special  sensation.  The  knee-jerks  were  increased, 
-electrical  reactions  normal,  and  there  was  incontinence  of  urine 
and  faeces.  He  became  much  emaciated,  and  died  of  broncho- 
pneumonia. Post-mortem  examination  revealed  a  pale  yellow  brain' 
of  unusual  hardness  throughout,  the  white  and  grey  substances,  as 
well  as  the  cerebellum,  being  extensively  involved  by  sclerosis. 

The  two  following  cases  of  brother  and  sister,  who  were  kindly 
shown  to  me  at  Darenth  Asylum  by  Dr.  F.  R.  P.  Ta^dor,  are 
probably  examples  of  diffuse  cerebral  sclerosis. 

The  mother  of  these  patients  is  healthy,  but  the  father  is  insane 

*  O.  Heubner,  "  Ueber  diffuse  Hirnsklerose,"  Charite-annalen,  1S97,  xxii. 


Diffuse  Sclerosis  251 

in  an  asylum.  The  father  and  mother  are  first  cousins ;  the  mother's 
father  and  mother  were  also  first  cousins.  There  have  been  four- 
teen children  born  in  the  family — five  are  dead  and  nine  living; 
there  is  "  something  the  matter  with  all  of  them,"  and  at  least  one 
other  is  mentalty  defective. 

Rose,  the  elder  patient,  was  born  prematurely  at  the  seventh 
month,  and  she  has  been  abnormal  from  birth.  She  commenced  to 
say  a  few  words  when  about  two  years  of  age,  and  made  attempts 
to  walk  at  three;  but  she  never  made  much  progress,  and  at  the 
age  of  twelve  years,  on  account  of  the  mental  deficiency  and  con- 
stant tremor,  she  was  sent  to  the  asylum.  She  proved  uneducable, 
and  the  tremor  steadily  became  worse.  When  I  saw  her  at  the 
age  of  twenty-one  years  she  was  a  bright-looking  girl,  apparently 
quite  happy  and  contented,  but  of  markedly  limited  mental  power. 
She  understood  a  good  deal  of  what  was  said  to  her,  and  made 
attempts  to  reply;  but  her  articulation  was  quite  unintelligible 
on  account  of  the  tremor.  She  spent  the  day  sitting  in  a  chair, 
and  was  quite  unable  to  walk,  or  even  stand,  without  support. 
There  was  spastic  rigidity,  with  inversion  and  adduction  of  both 
legs  and  feet;  the  knee-jerks  and  plantar  reflexes  were  exaggerated, 
and  ankle  clonus  was  well  marked.  The  head  was  never  still  in 
consequence  of  constant  rhythmic  up-and-down  and  side-to-side 
movements;  the  facial  muscles  were  also  affected,  giving  rise  to 
a  never-ending  series  of  extraordinary  grimaces.  These  move- 
ments were  described  as  chorea,  but  they  really  had  greater  re- 
semblance to  paralysis  agitans.  They  were  worse  under  observa- 
tion, but  ceased  during  sleep. 

The  brother,  William,  was  very  similar,  except  that  in  his  case 
the  rhythmic  movements  affected  the  whole  body — head,  face, 
arms,  hands,  and  legs.  It  was  impossible  for  him  to  pick  anything 
up,  or  to  retain  anything  in  his  hands,  but  the  grasp  of  the  hands 
showed  that  tolerable  muscular  strength  was  present.  He  under- 
stood what  was  said  to  him,  and  attempted  to  reply,  but  his  words 
were  quite  unintelligible.  He  had  a  moderate  amount  of  intelligence, 
and  obviously  observed  what  was  going  on  round  him,  and  he  was 
quite  clean  in  his  habits. 

{b)  Hypertrophic  Form. — This  condition  is  sometimes  described 
as  hypertrophy  of  the  brain,  but  it  is  to  be  borne  in  mind  that  the 
h5-pertrophy  concerns  the  interstitial  tissue  only,  and  not  the 
cerebral  neurones — that  it  is,  in  fact,  a  (probably  diffuse)  gliosis. 


252     Secondary  Amentia  and  its  Clinical  Varieties 

Hj^ertrophic  amentia  is  relatively  rare,  and  is  characterized 
by  an  enlargement  of  the  brain  and  skull  and  by  certain  bodily 
and  mental  symptoms.  The  largest  skull  of  this  variety  I  have 
seen  had  a  circumference  of  25  inches.  Owing,  however,  to  an 
increase  in  the  density  as  well  as  the  size,  the  brain  weight  is  often 
considerably  greater  than  would  be  expected  even  from  the  size 
of  the  skull.  Dr.  Fletcher  Beach  found  the  brain  of  a  boj'  who 
died  at  the  age  of  fifteen  to  weigh  62  ounces  (1,755  grammes). 
Dr.  Ireland  quotes  two  cases  described  by  Dr.  Daniel  Brunet.  The 
brain  of  one,  at  the  age  of  seventeen,  weighed  1,632  grammes; 
that  of  the  other,  dying  at  the  age  of  eighteen,  weighed  1,780 
grammes. 

Owing  to  the  cranial  enlargement,  these  cases  are  sometimes 
mistaken  for  hydrocephalus;  but,  as  pointed  out  by  Dr.  Fletcher 
Beach,  there  are  readily  recognizable  differences.  The  skull  of 
the  hypertrophic  ament  tends  to  be  square  in  shape  instead  of 
round,  and  there  are  sometimes  well-marked  frontal  prominences. 
In  hypertrophy,  the  greatest  circumference  is  at  the  level  of  the 
superciliary  ridges,  whereas  in  hydrocephalus  it  is  greatest  over 
the  temples.  Thus,  although  the  skull  of  the  hypertrophic  patient 
looks  massive,  it  has  not  that  "  top-heavy  "  appearance  so  char- 
acteristic of  the  hydrocephahc.  Further,  in  hydrocephalus  there 
is  usually  bulging  of  the  fontanelle  and  sutures,  whilst  in  h\'per- 
trophy  this  is  not  generally  the  case;  in  fact,  the  expansile  effects 
and  the  tendency  to  distend  the  skull  seem  to  be  much  greater 
in  the  former  than  in  the  latter  condition.  The  cranium,  having 
reached  a  certain  limit,  ceases  to  further  expand,  in  consequence 
of  the  contraction  of  the  neuroglia;  whilst  hydrocephalus  tends 
to  expand  the  skull  indefinitely. 

Hypertrophic  amentia  is  usually  accompanied  by  headache, 
which  may  be  very  severe,  and  by  epileptic  fits.  In  some  cases 
the  fits  diminish  in  frequency  and  severity,  and  they  may  entirely 
cease.  In  others  they  get  steadily  worse,  and  many  patients 
ultimately  die  of  exhaustion  following  a  series  of  fits.  In  a  con- 
siderable number  there  is  a  general  muscular  weakness  of  all 
parts  of  the  body,  so  that  the  balance  is  unsteady,  the  walk  slow 
and  tottering,  and  the  grasp  feeble.  Tremor  is  often  brought 
on  by  exertion.  In  consequence,  manual  work  is  performed  slowly, 
clumsily,  and  with  considerable  difficulty.  Speech  is  often  simi- 
larlv  affected.     jNIost  of  the  cases  I  have  seen  have  been  somewhat 


Diffuse  Sclerosis  253 

undersized,  heavy -looking  and  of  good  bodily  nutrition,  also  of 
cheerful  although  somewhat  simple  expression. 

The  degree  of  mental  defect  varies  very  much,  and  seems  to 
be  dependent  upon  the  frequency  with  which  convulsions  occur. 
Where  these  are  slight,  it  is  usually  one  of  mild  imbecility,  or 
even  merely  feeble-mindedness ;  but  if  the  fits  are  at  all  frequent, 
a  condition  amounting  to  idiocy  may  be  present.  Attacks  of  rage 
and  violence  have  been  described,  but  these  are  by  no  means 
constant,  and  I  doubt  whether  they  are  any  more  common  in  this 
than  in  other  varieties  of  amentia.  Certainly  some  of  these  persons 
are  harmless  and  thoroughly  good-tempered.  The  severe  cases, 
which  are  accompanied  by  frequent  fits,  seem  to  die  early,  and, 
as  far  as  one  can  judge  from  the  cases  which  have  been  recorded, 
few  survive  long  after  maturity.  This,  however,  is  by  no  means 
so  with  the  milder  forms,  in  whom  fits  are  comparatively  rare,  and 
at  the  present  time  there  is  one  of  these  patients  in  Earlswood 
Asylum  who  is  fifty-two  years  of  age,  and  seemingly  in  excellent 
health. 

Illustrative  Cases. 

W.  C.  T.,  male;  the  only  child;  no  morbid  heredity.  He  seemed 
in  every  way  normal  until  three  years  of  age,  when  he  had  an  acute 
illness,  which  the  mother  calls  "influenza  and  rheumatic  fever." 
It  was  accompanied  by  fever  and  very  great  pain  in  the  head.  He 
went  to  school  at  the  age  of  seven,  and  left  at  fifteen.  Was  in  the 
fourth  standard,  but  his  mother  admits  that  he  was  very  dull  at 
learning,  and  does  not  think  he  was  equal  to  fourth-standard  work. 
He  had  whooping-cough  at  the  age  of  nine,  which  was  accompanied 
by  six  fits.  There  were  no  further  fits  until  twelve  years  of  age, 
but  during  this  time  he  was  noticed  to  be  very  unsteady  in  standing 
and  walking,  and  he  would  frequently  fall  down  both  in  and  out 
of  school.  In  addition  to  being  somewhat  dull,  he  was  prone  to 
outbreaks  of  bad  temper  and  irritability,  and  was  at  times  spiteful. 
The  head  was  first  noticed  to  be  larger  than  usual  after  the  attack 
of  whooping-cough  at  nine  years. 

I  first  saw  him  when  he  was  fifteen  years  of  age.  He  was  under- 
sized, but  fat  and  heavy.  The  circumference  of  the  skull  at  the 
level  of  the  supra-orbital  ridges  was  23  inches;  there  was  no 
asjnnmetry  and  no  prominences;  the  fontanelles  were  closed.  The 
upper  and  lower  jaw-bones  were  also  larger  than  usual,  and  as  a 


254     Secondary  Amentia  and  its   Clinical  Varieties 

result  there  were  large  gaps  between  the  teeth.  The  teeth  them- 
selves were  poorly  developed,  and  many  were  decayed.  The 
palate  was  broad  and  shallow.  The  nose  was  strikingly  broad, 
with  prominent  fleshy  nostrils;  the  lips  were  thick  and  fleshy, 
and  the  mouth  large.  The  tongue  appeared  quite  normal,  but 
was  always  protruded  markedly  to  the  right  side.  There  was 
nothing  abnormal  about  ears  or  eyes.  The  external  genitals  were 
well  developed,  and  there  was  an  abundance  of  pubic  hair.  There 
was  considerable  rigidity  of  the  hands,  arms,  and  legs.  No  actual 
paralysis  was  present,  but  the  left  hand,  arm,  and  leg  were  definitely 
weaker  than  the  right,  and  he  walked  with  a  well-marked  limp. 
The  knee-jerks  could  not  be  obtained,  but  both  plantar  reflexes 
were  exaggerated,  particularly  the  left.  Whilst  under  examina- 
tion there  were  almost  constant  irregular  jerky  movements  re- 
sembling chorea;  these  also  were  most  marked  on  the  left  side. 
He  was  subject  to  tonic  convulsions,  averaging  four  or  five  dailv. 
During  these  the  right  eye  was  firmly  closed  and  the  face  drawn 
to  the  right,  the  left  eye  being  open.  Legs  and  arms  were  rigid 
and  drawn  up  on  to  the  trunk.  No  clonic  movements  and  no  loss 
of  consciousness.  There  were  no  sensory  defects,  memon,'  was 
good,  attention  rather  fitful.  He  understood  all  that  was  said  to 
him,  and  could  converse  quite  rationally,  although  his  speech  was 
thick,  slow,  and  hesitating.  He  used  to  stutter  a  great  deal,  but 
not  now.  He  could  read  and  write,  but  was  exceedingly  poor  at 
sums.  He  had  considerable  moral  and  religious  sense,  and  was 
obedient  and  well-behaved.  His  mental  status  was  one  of  mild 
f  eeble-mindedness . 

He  is  now  twenty-one  years  of  age,  and  has  been  under  my 
observ-ation  for  six  years.  At  the  present  time  the  cranial  circum- 
ference over  the  supra-orbital  ridges  is  23f  inches,  over  the  brow 
23I  inches.  His  height  is  5  feet,  weight  9  stones,  and  there  is 
practically  no  alteration  in  his  appearance.  There  have  been  no 
convulsions  for  several  years,  but  if  he  gets  upset  or  excited  the 
hands  and  arms  become  rigid  and  are  drawn  up  on  to  the  chest. 
His  walk  is  slow  and  somewhat  tottering,  and  his  balance  is  un- 
steady; but  if  he  is  allowed  to  take  his  time,  he  can  walk  several 
miles.  He  can  do  odd  jobs,  and  can  clean  a  pair  of  boots,  but  it 
takes  him  an  hour  to  do  so.  If  he  is  hurried  a  general  muscular 
tremor  sets  in,  which  makes  work  impossible.  His  hand-grasps 
are  fairly  good;  the  legs  are  spastic.     He  frequently  complains  of 


Plate  XA'III. 
SECONDARY  AMENTIA   DUE  TO   SCLEROSIS. 


Fig.  45. — A  case  of  so-called  "  h)-peitrophy  of  the  brain."    Age,  21  years. 


Fig.  46. — Hydrocephalic  and  microcephalic  imbeciles. 


To  face  page  254.] 


Tuberous  or  Nodular  Sclerosis  255 

headache,  which  he  refers  to  the  parietal  eminences.  There  is  a 
decided  improvement  in  his  mental  condition,  and  he  can  do  many 
small  jobs  about  the  house.  He  can  carr}'  a  parcel  or  a  message, 
but  his  mother  says  that  he  cannot  be  trusted  to  do  shopping,  as 
he  gets  into  a  hopeless  muddle  with  the  change.  His  temper  is 
irritable  and  perverse  at  times,  but  on  the  whole  he  is  obedient  and 
gives  no  trouble.  I  have  got  him  into  several  situations,  but  he 
has  been  discharged  from  each  in  turn  in  consequence  of  his  general 
incompetence.* 

It  is  worthy  of  note  that  the  increased  size  of  the  jaws,  with  the 
separation  of  the  teeth  and  the  large  and  broad  nostrils,  give  rise 
to  a  physiognomy  somewhat  resembling  acromegaly.  There  are, 
however,  no  other  signs  of  that  condition,  and  the  early  onset  is 
totally  unlike  it.  It  is  quite  possible,  however,  that  the  signs  which 
are  present  may  be  due  to  a  partial  sclerosis  of  the  pituitary  gland. 

I  have  quoted  this  case  somewhat  in  detail  because  it  seems  to 
me  to  be  a  ver}^  typical  example  of  that  form  of  hypertrophic 
amentia  in  which  fits  have  not  produced  serious  mental  degrada- 
tion. At  the  present  time  there  is  a  very  similar  case  in  Earls- 
wood  Asylum,  and  another  patient  of  this  type  whom  I  have 
known  for  over  ten  years  has  managed  during  that  time  to  earn 
his  keep  as  a  tradesman's  boy.  In  this  case,  however,  the  amentia 
is  less  marked,  and  his  employer  has  treated  him  with  considerable 
indulgence. 

Tuberous  or  Nodular  Sclerosis. 

In  this  form  of  sclerosis  the  overgrowth  of  neuroglia  occurs  as 
circumscribed  nodules  varying  in  size  from  a  pea  to  a  walnut. 
These  are  found  in  the  cortex  of  the  cerebral  hemispheres,  where 
they  form  hard  pale  masses,  which  frequently  project  slightly 
above  the  rest  of  the  brain,  and  are  usually  marked  by  a  central 
umbilication  due  to  contraction.  They  also  occur  as  protuberances 
projecting  into  the  lateral  ventricles,  and  in  one  case  examined  by 
myself  there  was  in  addition  a  dense  cap  of  sclerotic  tissue  imme- 
diately beneath  the  pia-arachnoid  over  several  regions  of  the  cortex. 
This  latter  may  possibly  represent  an  earlier  stage  of  the  cortical 
infiltration.  Bourneville  of  Paris  was  the  first  to  draw  attention 
to  this  form  of  sclerosis,  and  although  a  considerable  number  of 
cases  have  since  been  described  by  other  authors,  it  must  be  looked 

*  This  patient's  condition  is  practically  unchanged  five  years  later,  and 
during  this  time  there  have  been  no  convulsions. 


256     Secondary  Amentia  and  its  Clinical  Varieties 

upon  as  decidedly  uncommon.  During  the  last  few  years  the 
condition  has  attracted  much  interest  owing  to  the  discovery  in 
several  of  these  patients  after  death  of  tumours  in  the  kidneys, 
heart,  and  other  organs;  also  by  the  fact  that  a  certain  proportion 
of  them  have  suffered  from  that  curious  papular  growth  in  the 
skin  known  as  "  adenoma  sebaceum,"  which  has  been  described 
on  p.  146.  Thus  Fowler  and  Dickson,*  who  have  analyzed  the 
records  of  twenty-six  cases,  find  that  renal  tumours  were  present 
in  seventeen,  being  usually  bilateral  and  generally  described  as 
"cancerous";  heart  tumours  (rhabdomyomata)  were  mentioned 
as  occurring  in  four  cases;  tumours  of  the  thyroid,  thymus,  duo- 
denum, and  spleen  being  also  reported;  whilst  adenoma  sebaceum 
was  present  in  thirteen  out  of  the  twenty-six  cases. 

The  association  in  some  cases  of  the  nodules  in  the  brain  with 
the  kidney  tumours  and  skin  lesions,  led  Vogt,t  and  subsequently 
other  authors,  to  regard  the  combination  as  a  distinct  clinical  entity, 
and  Dr.  E.  B.  Sherlock|  has  proposed  for  it  the  name  of  "epiloia." 
But  it  is  extremely  doubtful  if  this  association  is  sufficiently  con- 
stant to  warrant  such  a  view.  Whether  the  kidney  tumours  have 
ever  been  present  without  the  cerebral  sclerosis  I  do  not  know, 
since  such  cases  would  be  unlikely  to  come  under  the  observation 
of  the  psychiatrist;  but  Dr.  R.  Langdon  Down  tells  me  that  he  has 
made  a  post-mortem  upon  a  patient  who  suffered  from  adenoma 
sebaceum  in  which  there  was  no  sign  of  either  sclerosis  of  the  brain 
or  kidney  tumours;  and  Crocker  describes  two  cases  of  adenoma 
in  which  there  were  certainly  no  indications  of  the  brain  lesions, 
one  in  a  clever  boy  of  eleven,  and  another  in  an  intelligent  woman 
of  forty-eight.  Out  of  the  nine  cases  of  "  epiloia  "  described  by 
Dr.  E.  B.  Sherlock,  there  are  three  in  which  fits  are  absent  (or 
not  stated),  so  that  there  is  no  reason  to  suspect  the  presence  of 
cerebral  sclerosis ;  whilst  adenoma  only  appears  to  be  at  all  marked 
in  three,  to  be  not  pronounced  in  three,  and  to  be  absent  (or  not 
stated)  in  three  cases.  On  the  other  hand,  it  is  an  undoubted 
fact  that  the  typical  brain  lesions  have  been  found  in  many  patients 
without  either  the  kidney  tumours  or  the  adenoma,  and  such 
cases  have  been  described  by  Boumeville,  Bonfigli,  and  myself. 
On  the  whole,  therefore,  since  the  name  of  "nodular  "  or  "  tuber- 

*  J.  S.  Fowler  and  W.  E.  C.  Dickson,  Lancet,  May  14,  1910,  p.  1351. 
t  H.  Vogt,  Monatsschr.  fiir  Psych,  und  Neurolog.,  Band  xxiv.,  1908. 
I  E.  B.  Sherlock,  "  The  Feeble-minded,"  191 1. 


Tuberous  or  Nodular  Sclerosis  257 

ous  "  sclerosis  is  now  sanctioned  by  many  years'  usage,  and  describes 
a  condition  about  which  there  is  no  doubt,  it  would  perhaps  be 
wiser  to  postpone  the  coining  of  a  new  name  until  we  are  quite 
sure  that  the  condition  to  which  is  it  applied  really  exists. 

In  most  cases  of  tuberous  sclerosis  there  is  a  well-marked  neuro- 
pathic family  history,  and  this,  with  the  usually  early  onset  of 
the  symptoms  and  the  absence  of  any  external  determining  factor, 
rather  suggests  that  the  disease  is  a  developmental  anomaly  com- 
plicating imperfect  neuronic  growth.  If  this  were  so,  it  would  fall 
into  the  group  of  primary  amentia;  but  in  view  of  the  pronounced 
nature  of  the  cerebral  lesions  I  have  provisionally  included  it  in 
this  place.  It  may  be  mentioned  that  the  application  of  the 
Wassermann  reaction  by  Gordon*  to  seven  cases  gave  a  positive 
result  in  one. 

Convulsions  are  usually  the  first  symptom  to  attract  attention, 
being  noticed  in  most  instances  towards  the  end  of  the  first  year. 
In  a  few  cases,  however,  they  are  preceded  by  irregular  muscular 
twitching  or  head-nodding.  They  continue  during  the  life  of  the 
patient  with  tolerable  frequency,  in  some  cases  occurring  daily, 
in  others  at  intervals  of  a  few  days.  They  are  indistinguishable 
from  ordinary  idiopathic  epilepsy,  although  minor  attacks  often 
occur  as  weU.  Mental  impairment  is  noticed  in  the  early  years 
of  life,  and  varies  from  a  condition  of  mild  imbecility  permitting 
of  some  training,  to  a  more  pronounced  imbecility  or  idiocy;  usually 
it  is  of  a  severe  grade.  Headache  is  often  present,  also  muscular 
tremor,  and  the  balance  may  be  unsteady  and  the  gait  tottering; 
but  definite  rigidity  and  contractures,  like  those  met  with  in  the 
•diffuse  variety,  are  absent.  There  are  no  sensory  disturbances. 
Progressive  dementia  supervenes,  and  death  usually  takes  place  in 
status  epilepticus  before  the  age  of  maturity.  In  some  patients  it 
results  from  pneumonia. 

It  occasionally  happens  that  in  patients  presenting  these  symp- 
toms kidney  tumours  can  be  palpated  during  life,  or  there  may 
be  urinary  changes  in  the  shape  of  dropsy  or  uraemia.  The  diag- 
nosis of  nodular  sclerosis  may  then  be  made  with  tolerable  cer- 
tainty; but  in  other  instances  it  must  be  dependent  upon  the 
presence  of  the  fits,  associated  with  twitching,  head-nodding,  and 
tremor,  and  unsteady  and  tottering  gait,  headache,  and  progressive 
mental  impairment. 

*   J.  L.  Gordon,  Lancet,  September  20,  191 3,  p.  S61. 

17 


258     Secondary  Amentia  and  its  Clinical  Varieties 

Illustrative  Cases. 

W.  S.,  male.  Father  insane;  father's  mother  epileptic  and 
insane.  The  patient  has  been  subject  to  epileptic  fits  since  a  year 
old.  He  has  always  been  of  deficient  intellect,  and  was  unable 
to  learn  at  school.  He  was  subject  to  attacks  of  excitement  and 
violence,  and,  according  to  his  mother,  would  take  up  a  knife 
to  anyone  on  the  slightest  provocation.  At  the  age  of  thirteen 
he  became  so  troublesome  that  he  had  to  be  sent  to  the  asylum. 
On  admission  he  was  found  to  be  a  pronounced  imbecile,  possessing 
numerous  stigmata  of  degeneracy.  He  understood  what  was  said 
to  him,  and  was  able  to  converse,  but  in  a  very  simple  and  childish 
manner.  He  had  a  great  fancy  for  drawing,  but  no  ability.  He 
was  subject  to  frequent  epileptic  fits  and  occasional  paroxysms 
of  excitement.  There  was  no  paralysis.  His  rnemory  gradually 
became  defective  and  his  articulation  indistinct.  Salivation  was 
constant.  He  became  more  and  more  demented,  and  died  at  the 
age  of  nineteen  from  exhaustion  consequent  upon  status  epilepticus- 
lasting  seven  days.     During  this  time  he  had  406  convulsions. 

Post-Mortem  Appearances. — The  skull  was  s^nnmetrical  and  the 
bone  very  dense,  but  not  thicker  than  normal.  The  diira  mater 
and  pid-arachnoid  membranes  were  natural,  the  latter  stripping 
with  undue  readiness  from  the  sclerotic  portions  of  brain  described 
below.     There  was  no  excess  of  cerebro-spinal  fluid. 

Brain.— The  weight  (including  pons  and  cerebellrun)  was  1,445 
grammes,  representing  a  considerable  increase  relative  to  the 
size  of  the  organ;  the  two  hemispheres  were  of  equal  weight.  On 
stripping  off  the  pia-arachnoid  it  was  seen  that  several  convolu-^ 
tions  of  both  hemispheres  were  smoother,  paler,  protuberant,  and 
much  more  compact  in  appearance  than  the  rest  of  the  brain,  and 
from  these  the  membrane  stripped  with  great  readiness,  although 
clinging  to  the  other  regions  in  a  natural  manner.  The  hardest  of 
these  protuberances  were  marked  by  a  central  umbilication.  On 
making  a  section  into  these  convolutions  they  were  found  to  be 
extremely  firm  and  dense  owing  to  portions  of  the  brain  substance 
being  replaced  by  sclerotic  tissue.  These  sclerotic  areas  were  abun- 
dant in  both  hemispheres,  being  chiefl}-  confined  to  the  superficial 
grey  matter;  they  were  somewhat  irregular  in  outline,  and  tended 
to  pass  gradually  into  the  adjacent  brain  tissue.  In  the  portions 
involved  the  cortical  striae  were  very  hregular  and  much  obscured; 


Tuberous  or  Nodular  Sclerosis  259 

but  on  the  whole  the  condition  was  one  more  readily  appreciable 
by  the  sense  of  touch  than  that  of  sight,  the  extreme  hardness  of 
the  areas  being  their  most  characteristic  quality. 

Attached  by  a  broad  base  to  the  corpora  striata,  and  projecting 
inwards  therefrom  into  the  cavity  of  the  lateral  ventricles,  were 
numerous  small  nodules  varying  in  size  from  that  of  a  grape-stone 
to  a  large  pea,  and  consisting  of  a  very  dense  tissue  similar  to  that 
in  the  brain.  On  section  these  nodules  could  be  seen  with  the 
naked  eye  to  slightly  infiltrate  the  adjacent  portion  of  the  grey 
matter  from  which  the}'  grew.  The  lateral  ventricles  were  not 
dilated  and  the  ependyma  was  normal. 

Cerebellum. — There  was  obvious  naked-eye  atrophj^  of  several 
leaflets  on  the  upper  surface  of  both  hemispheres,  chiefly  confined 
to  the  lobus  chvi.  The  medulla  and  spinal  cord  showed  no  naked- 
eye  change.  Broncho-pneumonia  was  present,  but  no  tumours 
of  skin,  kidneys,  or  other  organs. 

Microscopical  Examination. — Sections  were  examined  from  several 
regions  of  the  brain,  medulla,  cerebellum,  and  spinal  cord. 

Brain. — The  dense  areas  described  above  are  seen  to  consist 
largely  of  glia  tissue.  In  some  of  them  the  glia  cells  are  com- 
paratively few  and  of  a  fully  formed  appearance,  there  being 
present  an  abundant  meshwork  of  fibres;  in  other  areas,  however, 
the  cells  are  much  more  numerous  and  of  more  recent  formation, 
and  the  sclerosis  is  not  so  dense.  The  areas  are  not  sharply  defined, 
but  pass  insensibly  into  the  surrounding  brain  tissue,  and  they  are 
comparatively  poorly  supplied  with  bloodvessels.  The  nerve  cells 
of  the  cortex  are  very  irregularly  arranged,  their  apical  processes 
pointing  in  all  directions.  In  addition,  a  large  number  of  them 
have  the  ordinary  appearance  of  imperfectly  developed  cells,  and 
a  considerable  number  of  actual  neuroblasts  are  also  present  in 
the  superficial  layers.  A  large  number  of  the  cells,  especially  the 
smaller  and  medium-sized  pyramids,  are  also  undergoing  a  chronic 
form  of  degeneration,  being  small  and  withered-looking,  the  nuclear 
membrane  often  indistinct,  the  processes  few  and  attenuated,  and 
the  cell  body  containing  a  considerable  collection  of  pigment.  In 
the  region  of  the  sclerotic  areas  the  lamination  is  very  irregular, 
probably  largely  the  result  of  the  neuroglial  overgrowth.  In  some 
of  the  convolutions  there  is  a  dense  band  of  neuroglia  on  the  surface 
of  the  brain  immediately  underneath  the  pia-arachnoid  membrane, 
and  superficial  to  the  tangential  fibres.     The  nodules  projecting 


2  6o     Secondary  Amentia  and  its  Clinical  Varieties 

from  the  corpora  striata  consist  of  almost  pure  glia  tissue,  the 
cells  of  which  have  a  peculiar  whorl-Uke  arrangement.  They  are 
covered  by  an  ependyma  of  perfectly  normal  structure.  Sections 
stained  by  Marchi's  method  reveal  the  absence  of  any  recent 
degeneration  amongst  the  meduUated  fibres  of  the  white  matter. 
The  tangential,  super-  and  inter-radial  fibres,  as  well  as  those  com- 
posing the  outer  line  of  Baillarger,  are  considerably  diminished 
in  number  in  all  parts  of  the  brain.  There  are  two  or  three  small 
foci,  situated  within  the  sclerotic  areas,  in  which  granules  of 
hsematoidin  occur,  apparently  indicating  an  old  hsemorrhage;  the 
endothelial  cells  of  some  of  the  capillaries  contain  collections  of 
black  pigment  (Marchi  sections),  but  otherwise  there  is  no  struc- 
tural alteration  in  the  vessels  of  either  the  brain  or  membranes,  and 
no  evidence  of  any  inflammatory  change. 

Cerebellum. — Sections  of  the  atrophied  portions  show  that  there 
is  marked  diminution  in  the  number  of  Purkinje's  cells  and  also 
in  the  projection  fibres;  but  Purkinje's  cells  do  not  contain  any 
pigment  like  that  in  the  cells  of  the  brain. 

Medulla  and  Cord. — There  is  slight  interstitial  sclerosis  (no 
Marchi  change)  in  the  crossed  pyramidal  tracts  traceable  as  far 
as  the  mid-dorsal  region;  also  in  the  antero-lateral  columns  as  far 
down  as  the  fourth  cervical  segment.  The  ceUs  of  the  anterior 
lioms  are  plentiful  and  well  formed,  many  of  them  contain  a  con- 
siderable collection  of  pigment  which  stains  black  with  Marchi's 
stain,  but  otherwise  they  appear  to  be  normal.  There  is  no  sign 
of  any  diffuse  sclerosis  in  the  cord  like  that  met  with  in  the  brain.* 

A  case  presenting  identical  histological  features  with  the  above 
was  described  by  Dr.  Joseph  Sailer.f  In  this  there  was  an  insane 
and  alcohohc  heredity,  and  spasms  began  at  the  age  of  ten  months. 
The  mental  condition  was  one  of  low-grade  idiocy.  Epileptic 
convulsions  were  frequent,  and  the  patient  died,  aged  fifteen,  of 
exhaustion  after  a  succession  of  fits.  In  this  case  there  was  a  huge 
tumour-like  mass  in  the  right  kidney,  and  smaller  growths  in  the 
left. 

The  two  cases  described  by  Bonfigli,|  epileptic  imbeciles  of  seven 

*  This  case  was  reported  by  the  author  in  "  Archives  of  Xeurolog^^"  vol.  ii., 

1903.  P-  402. 

f  J.  Sailer,  "  Hj-pertrophic  Xodular  Ghosis,"  American  Journal  of  Nervous 
and  Mental  Disease,  1898,  p.  402. 

%  R.  BonhgU,  "  t  ber  tuberose  Sklerose,"  Monatsschr.  f.  Psych,  u. 
Neurolog.,  Band  xxvii..  May,  1910. 


Tuberous  or  Nodular  Sclerosis  261 

and  five  years  respectively,  presented  similar  histological  appear- 
ances. Another  similar  case  was  described  by  Dr.  Margaret 
B.  Dobson.*  In  this  there  was  a  marked  family  history  of  tuber- 
culosis, alcoholism,  and  epilepsy,  and  the  patient,  a  male  epileptic 
idiot,  died  at  the  age  of  ten  years  from  pneumonia  accelerated  by 
exhaustion  from  epilepsy. 

The  earliest  symptom  noticed  was  "  twitching  of  the  face  and 
nodding  of  the  head  "  when  he  was  three  or  four  weeks  old.  Con- 
vulsions resembling  those  of  idiopathic  epilepsy  commenced  one 
year  after  birth.  When  admitted  to  the  asylum,  at  the  age  of 
five  years,  he  was  described  as  being  a  low-grade  idiot,  unable  to 
do  anything  for  himself,  quite  incapable  of  answering  the  simplest 
questions,  but  made  inarticulate  noises;  wet  and  dirty  in  his  habits. 
His  gait  was  peculiar  in  that  he  had  a  tendency  to  walk  on  his  toes, 
and  seemed  incapable  of  walking  in  a  straight  line.  He  would 
rotate  round  any  fixed  object  on  the  floor  in  a  direction  from  right 
to  left.  He  had  both  grand  mal  and  petit  mal,  and  had  an  average 
of  two  to  six  fits  per  day.  He  suffered  from  adenoma  sebaceum. 
Dr.  Dobson  gives  a  very  good  account  of  the  naked-eye  and  micro- 
scopical appearances  of  the  brain  (illustrated  by  four  photographs) , 
and  from  this  it  is  clear  that  the  case  was  pathologically  identical 
with  that  of  my  own  just  described.  With  the  exception  of  red 
hepatization  of  the  lungs,  the  body  organs  showed  no  changes  of 
interest. 

Drs.  Fowler  and  Dicksonf  describe  the  case  of  a  female  child 
who  was  admitted  into  hospital,  at  the  age  of  one  year,  suffering 
from  convulsions.  She  had  previously  appeared  normal.  On 
admission  she  was  semiconscious  and  suffering  from  clonic  spasm 
on  the  left  side  of  the  face.  The  limbs  were  flaccid,  the  knee-jerks 
were  active,  Kernig's  sign  was  absent,  and  the  pupils  were  equal 
with  left  internal  strabismus.  She  died  a  month  afterwards  of 
empyema.  Post-mortem  examination  showed  tuberous  sclerosis 
of  the  brain  with  rhabdomyoma  of  the  heart,  but  no  changes  in 
the  skin,  kidneys,  or  other  organs.  The  immediate  cause  of  death 
was  broncho-pneumonia,  empyema,  and  collapse  of  lung. 

*  Margaret  B.  Dobson,  Lancet   December  8,  1906,  p.  1583. 
t   Op.  cit. 


262     Secondary  Amentia  and  its  Clinical  Varieties 


HYDROCEPHALIC  AMENTIA. 

Primary  amentia  may  be  complicated  by  hydrocephalus,  and 
"this  condition  is  even  occasionally  found  in  making  post-mortem 
examinations  of  microcephalics.  The  term  "  hydrocephalic  amentia," 
however,  is  better  restricted  to  those  cases  in  which  the  mental 
deficiency  is  secondary  to  this  lesion. 

As  to  the  cause  of  hydrocephalus  much  uncertaint}^  exists. 
Some  cases  are  the  after-effect  of  chronic  meningitis  or  tumours 
(usually  syphilitic  or  tubercular)  of  the  base  of  the  brain ;  in  others 
no  antecedent  lesion  can  be  discovered.  However  produced,  the 
essential  condition  consists  of  an  accumulation  of  cerebro-spinal 
fluid,  which  may  amount  to  several  pints,  within  the  ventricles 
of  the  brain.  In  consequence  of  the  pressure  of  this  fluid,  the 
brain  tissue  adjacent  to  the  ventricles  is  gradually  thinned  and 
destroyed.  In  extreme  cases  it  may  be  reduced  to  a  mere  shell  but 
a  fraction  of  an  inch  in  thickness,  so  that  the  hemispheres  resemble 
a  huge  cyst.  The  parts  least  affected  are  the  cerebellum  and  basal 
gangha. 

The  expansile  force  of  the  fluid  is  usually  marked  upon  the  skull, 
the  bones  of  which  become  widely  separated;  and  this,  with  the 
general  enlargement,  produces  a  clinical  picture  which  cannot  well 
be  mistaken.  But  in  some  instances  hydrocephalus  may  exist 
with  a  smaU  skull,  owing  to  premature  ossification  of  the  cranial 
bones,  and  the  condition  will  then  only  be  revealed  after  death. 
Such  are  usuaUy  pronounced  idiots;  convulsions  are  frequent,  and 
death  takes  place  early. 

Occasionally  hydrocephalus  exists  before  birth,  but  if  at  all 
severe  it  is  rarely  possible  for  the  child  to  be  born  aUve;  and  in 
the  majority  of  cases  met  with  the  onset  takes  place  in  the  first 
few  months,  or  it  may  be  years,  of  life.  There  can  be  no  doubt 
that  a  great  proportion  of  children  so  affected  die  within  a  few 
years.  In  other  cases  a  spontaneous  cure  takes  place,  and  it  has 
even  been  affirmed  by  Edinger  that  a  mild  hydrocephalus  occurring 
in  childhood,  which  becomes  cured,  may  actually  favour  mental 
development  owing  to  the  distension  of  the  skull  cavity  causing  a 
lessened  resistance  to  the  growth  of  the  brain.  In  most  cases,  how 
ever,  there  results  some  degree  of  mental  deficiency. 

The  subsequent    course  varies,   and  in  the  main  there  are  two 


Plate  XIX. 
SECONDARY  AMKNTIA   DUE  TO    FnDROCEPHALUS. 


HH^ 

R 

'^ 

f       1 

^■L 

V 

i 

^^^^^j^ 

m:^-^ 

Fig.  47. — Male  hydrocephalic.     Age,  ij  years. 
{FrojH  a  photograph  lent  by  Dr.  J.  Thomson.) 

MICROCEPHALIC  AMENTIA. 


Fig.  48.— Female  microcephalic.      A^-e,  4;^'  months. 
{Ffo/n  a  photograph  lent  by  Dr.  J.  Thomson.) 

To /ace  page  262.] 


Hydrocephalic  Amentia  263 

types.  In  one,  whilst  the  patient  may  be  imbecile,  or  even  idiotic, 
the  mental  condition  is  of  secondary  importance,  in  view  of  the 
active  and  steadily  progressive  nature  of  the  disease  to  which  it 
is  due.  Such  children  are  acutely  ill,  the  body  is  wasted,  convulsions 
are  frequent,  and  severe  paralysis  is  generally  present.  Many  of 
them  are  bedridden.  They  may  be  blind  or  deaf  from  the  pressure 
of  fluid,  and  optic  atrophy  is  often  seen.  Although  the  alienist 
may  be  consulted  with  regard  to  these  cases,  their  place  is  the 
hospital  ward,  and  not  the  special  institution,  and  death  soon 
closes  the  scene.  In  some  instances  considerable  amelioration  of 
the  mental  symptoms  takes  place  immediately  before  death. 

The  second  type,  those  cases  usually  seen  in  special  institutions, 
or  which  come  under  notice  on  account  of  amentia,  are  those  in 
which  the  hydrocephalus  is  either  increasing  very  slowly  or  has 
undergone  spontaneous  arrest.  In  these  cases  the  mental  deficiency 
varies  from  a  mild  degree  of  feeble-mindedness  to  pronounced 
imbecility,  and,  as  a  rule,  a  moderate  amount  of  improvement  takes 
place  as  a  result  of  special  training.  Dr.  Ireland  quotes  the  case 
of  a  boy  under  his  care  who  lost  his  hearing  after  being  several  years 
at  Larbert,  and  gradually  lost  many  of  the  words  he  had  learned. 
"  He  was  taught  a  number  of  figurative  signs,  and  also  to  spell  on 
his  fingers;  and  although  he  had  the  additional  disadvantage  of 
obscurity  of  sight — having  dimness  of  the  cornea,  resulting  from 
ophthalmia — his  progress  was  as  well  marked  as  that  of  any  pupil 
in  the  establishment," 

The  majority  of  hydrocephalic  aments  are  quiet,  confiding, 
affectionate,  and  obedient,  and  although  paresis  may  prevent  the 
performance  of  much  in  the  way  of  manual  work,  they  are  usually 
very  willing  to  do  what  they  can.  Owing  to  their  muscular  weak- 
ness, movements  are  clumsy  and  badly  co-ordinated,  and  in  some 
cases  severe  paralysis  may  be  present.  The  legs  are  more  fre- 
quently and  more  severely  involved  than  the  arms.  Impairment 
of  sight  and  hearing  are  also  common;  strabismus  is  frequent; 
and  in  the  more  severe  cases  nystagmus  occurs.  Epileptic  con- 
vulsions are  usually  present  in  the  acute  stage,  but  tend  to  diminish, 
and  often  disappear  altogether,  in  the  chronic  cases  seen  in  in- 
stitutions. Most  patients  are  undersized,  but  there  are  no  stigmata 
of  degeneracy.     (See  Plates  XVIII.  and  XIX.,  Figs.  46  and  47.) 

The  peculiar  enlargement  of  the  skull  makes  diagnosis  easy. 
The  hydrocephalic  skull  is  uniformly  increased  in  all  directions, 


264     Secondary  Amentia  and  its  Clinical  Varieties 

and  thus  tends  to  assume  a  globular  shape.  The  forehead  is  Jiigh 
and  projecting,  and  there  is  usually  a  characteristic  bulging  at 
the  root  of  the  nose,  but  the  greatest  circumference  is  at  the  level 
of  the  temples.  The  fontenalle  is  tense,  and  the  sutures  often 
widely  separated.  In  the  arrested  cases,  however,  these  become 
filled  in  with  Wormian  bones,  and  the  component  parts  of  the 
cranium  become  firmly  united.  The  scalp  is  thinned,  and  often 
marked  by  large  and  prominent  veins.  The  excessive  size  of  the 
cranium,  in  conjunction  with  the  small  face,  causes  the  head,  as 
seen  from  the  front,  to  have  a  very  characteristic  conformation, 
resembling  an  inverted  pyramid,  thereby  producing  a  curiously 
"  top-heavy  "  appearance.  The  circumference  varies  from  a  little 
above  the  normal  to  as  much  as  30  inches  or  more.  The  average 
measurement  of  the  chronic  cases  seen  in  institutions  is  about 
25  or  26  inches,  but  there  is  no  constant  relationship  between  the 
size  of  the  skull  and  the  degree  of  mental  impairment.  The  prog- 
nosis will  depend  upon  whether  the  disease  is  stationary  or  slowly 
progressing.  In  the  latter  dementia  is  usually  the  ultimate  result. 
The  two  conditions  which  might  be  confounded  with  hydro- 
cephalus are  hypertrophic  amentia  and  rickets.  The  distinction 
in  regard  to  the  former  of  these  has  already  been  given.  In  rickets 
the  skull  is  often  enlarged,  but  such  is  due  to  a  thickening  and 
increased  density,  and  not  a  distension.  Moreover,  the  rickety 
skull  is  usually  asymmetrical,  bossed,  and  ridged;  the  fontanelle, 
if  still  open,  is  depressed,  and  not  elevated;  there  is  an  absence  of 
the  thin  and  prominently  veined  scalp,  and  other  signs  of  rickets 
are  present. 

Illustrative  Cases. 

G.  P.,  male,  was  admitted  into  the  Littleton  Home  for  Defective 
Children  when  six  years  of  age.  He  was  an  orphan,  and  no  history 
bearing  upon  his  condition  was  obtainable.  He  was  a  delicate- 
looking  boy  of  average  height,  with  a  typical  hydrocephalic  skull, 
the  circumference  of  which  was  22|  inches.  The  palate  was  high 
and  saddle-shaped,  the  teeth  irregular.  There  was  left  internal 
strabismus,  also  deficient  power,  but  no  definite  paralysis,  of  the 
left  arm  and  leg.  He  dragged  both  feet  in  walking,  and  the  body 
balance  was  poor.  He  knew  his  letters  and  numbers,  and  could 
spell  a  few  simple  words,  and  his  mental  condition  generally  was 
one  of  mild  defect.     Articulation  was  good,  and  his  disposition 


Hydrocephalic  Amentia  265 

was  bright  and  cheerful.  There  was  very  little  change  for  three 
or  four  months,  although  the  boy  made  no  headway  in  school.  He 
then  began  to  be  silent  and  pensive,  and  to  lose  interest  in  his 
surroundings.  The  physical  signs  also  increased,  the  legs  became 
definitely  spastic,  so  that  walking  was  impossible,  and  all  move- 
ments were  performed  with  difficulty.  By  the  end  of  six  months 
the  cranium  had  increased  h  inch  in  circumference,  and,  as  he  was 
becoming  physically  helpless  and  showing  signs  of  dementia,  I 
was  compelled  to  discharge  him. 

C.  H.,  male.  The  fifth  born  of  a  family  of  eight,  two  of  whom 
are  said  to  be  in  good  health,  although  one  is  a  heavy  drinker.  A 
third  is  "very  delicate,"  and  the  remainder  died  in  infancy;  one 
was  a  cripple.  The  father  died,  aged  fifty-two,  of  bronchitis;  the 
mother  died,  aged  forty-seven,  of  general  paralysis.  The  patient 
seemed  all  right  at  birth,  but  had  a  "  fit  "  when  a  year  old,  and 
from  that  time  his  head  was  noticed  to  get  rapidly  bigger.  He 
did  not  walk  until  late,  and  then  very  badly,  and  he  always  seemed 
more  simple  and  childish  than  other  children.  He  made  little 
progress  at  school,  and  at  the  age  of  fourteen  was  admitted  to 
an  imbecile  institution.  He  remained  there  for  two  years,  but 
becoming  destructive  and  violent,  he  was  transferred  to  an  asylum. 
He  was  a  pronounced  hydrocephalic,  in  poor  physical  condition, 
but  clean  in  his  habits;  able  to  converse,  and  capable  of  helping 
a  little  in  the  wards.  The  head  increased  in  size,  and  he  gradually 
became  more  helpless.  He  is  now  eighteen  years  of  age,  and  has 
been  bedridden  for  over  a  year.  His  condition  is  as  follows:  The 
skull  is  typically  hydrocephalic,  and  measures  25  inches  in  cir- 
cumference. There  is  spastic  paresis  of  both  legs  from  the  thighs 
downwards;  he  can  just  stand,  but  is  quite  unable  to  walk.  The 
arms  do  not  appear  to  be  affected.  The  knee-jerks  are  increased, 
and  double  ankle  clonus  is  present;  also  Babinsky's  toe  sign.  On 
making  movements  a  marked  clonus  of  the  legs  appears,  but  there 
are  no  convulsions.  He  can  hear  and  see,  but  is  of  decidedly 
defective  understanding.  As  a  rule,  when  questioned,  he  gazes 
at  one  in  a  stolid,  helpless  way,  and  makes  no  attempt  to  reply; 
when  he  does  speak,  his  words  are  unintelligible.  He  pulls  to 
pieces  everything  which  comes  into  his  hands,  but  takes  practically 
no  notice  of  persons  or  things  round  him.  It  is  obvious  that  the 
disease  is  rapidly  progressing. 

/.  T.,  male.     The  fourth  of  a  family  of  five,  of  whom  one  died 


266     Secondary  Amentia  and  its  Clinical  Varieties 

in  infancy;  the  others  are  alive  and  well.  ^There  is  insanity  on 
the  father's  side,  and  consumption  on  the  mother's.  The  patient 
was  bom  with  a  very  big  head,  labour  being  much  prolonged.  He 
did  not  walk  until  turned  four  years,  and  has  always  been  clumsy 
in  his  movements.  He  was  a  little  backward  at  school,  but  no 
marked  mental  abnormality  was  noticed  until  the  age  of  ten, 
when  he  began  to  get  passionate  and  difficult  to  control.  He 
showed  a  remarkable  memory  for  ages,  and  his  mother  says  that 
he  knew  the  age  of  every  one  of  their  numerous  relations. 

He  left  school  aged  fourteen,  and  was  put  to  bootmaking;  but 
he  never  did  much  good,  and  after  a  short  time  he  was  taken  away. 
He  remained  at  home  pottering  about,  but  doing  no  work,  until 
thirty- four  years  of  age.  A  change  then  came  over  him;  he  began 
to  wander  about  at  night,  and  sometimes  stayed  away  from  home 
for  several  days  together.  He  would  put  tobacco  into  the  teapot, 
and  do  similar  foolish  things.  He  became  rambling  in  his  con- 
versation, and  said  that  "  Jack  the  Ripper  "  had  tried  to  cut  his 
throat.  He  refused  his  food,  saying  that  it  had  been  drugged. 
Finally  he  attacked  his  mother  with  a  knife,  and  became  so  maniacal 
that  he  had  to  be  sent  to  an  asylum. 

On  admission  he  had  a  typical  hydrocephalic  head,  convergent 
strabismus,  and  slight  dragging  of  the  left  leg.  He  was  loquacious, 
but  of  decidedly  feeble  intellect.  The  maniacal  condition  passed 
off,  and  he  became  quiet  and  well-behaved,  and  he  remained  in 
this  condition  for  several  years,  subject,  however,  to  delusions 
that  some  unknown  persons  put  poison  into  his  food.  Then  the 
legs  became  weaker,  so  that  he  was  unable  to  get  about,  and  now, 
at  the  age  of  forty-five  years,  he  is  bedridden.  There  is  weU- 
marked  spastic  paraplegia, .  so  that  he  is  unable  to  walk,  or  even 
stand,  without  support.  The  arms  are  unaffected.  The  knee- 
jerks  are  increased,  and  Babinsky's  sign  is  present  on  the  right  side. 
Both  legs  and  feet  are  blue  and  cold.  There  is  no  diminution  in 
tactile  sensation  over  any  part  of  the  body,  and  his  power  of  local- 
izing touch  is  remarkably  good.  He  frequently  complains  of  a 
girdle  sensation  round  the  epigastrium.  There  is  fine  tremor  of 
the  hands  on  extension,  and  of  the  legs  on  attempting  movement, 
but  no  convulsions  of  any  kind.  The  special  senses  are  normal. 
Articulation  is  slightly  defective,  but  speech  is  coherent  and  rational. 
Memory  is  very  good  indeed.  He  notices  all  that  goes  on  round 
him,  and  can  give  a  very  good  account  of  his  past  life,  but  his  ideas 


Syphilitic  Amentia  267 

are  childish  and  his  judgment  and  reasoning  defective.  He  can 
read,  write,  and  do  sums  remarkably  well.  He  has  lately  developed 
incontinence.     The  cranial  circumference  is  25^  inches. 


SYPHILITIC  AMENTIA. 

The  proportion  of  total  aments  in  whom  a  history  or  definite 
signs  of  syphilis  exist  is  comparatively  small;  but  the  application 
■of  the  Wassermann  reaction,  which  has  now  been  made  by  various 
•observers  (see  p.  48)  to  a  large  number  of  mentally  defective 
persons,  leads  to  the  conclusion  that  syphilis  may  occur  to 
a  much  greater  extent  than  was  formerly  thought.*  In  the 
great  majority  of  these  cases,  however,  other  factors,  generally  a 
psychopathic  inheritance,  are  present  in  addition.  I  shall  restrict 
the  term  "  syphilitic  amentia  "  to  those  which  appear  to  be  directly 
due  to  the  specific  virus. 

Whether  this  poison  acts  directly  upon  the  cerebral  neurones 
or  indirectly  upon  them  by  interfering  with  their  nutrition — 
whether,  in  fact,  they  are  poisoned  or  starved,  is  a  moot  point. 
On  the  whole,  I  am  inclined  to  think  the  former  is  the  case,  and  that 
persistent  antisyphilitic  treatment  from  the  very  beginning  of  life 
might  do  much  to  reduce  the  number  of  these  cases.  Unfortu- 
nately, by  the  time  attention  is  attracted  to  the  patient's  mental 
condition  the  damage  has  been  done,  and  such  treatment  is  of 
no  avail.  In  persons  suffering  from  syphilitic  amentia  there  will 
usually  be  a  history  of  the  ordinary  infantile  s3miptoms  of  this 
•■disease,  and  the  characteristic  lesions — viz.,  keratitis.  Hut  chin 
son's  teeth,  scars,  depressed  nose,  etc. — are  generally  found  in 
after-life.  But  it  seems  also  probable  that  the  development  of 
the  brain  may  be  arrested  by  the  poison  without  any  of  these 
syphilitic  lesions  being  produced,  and  then  the  diagnosis  can  only 
be  inferred  from  the  presence  of  a  positive  Wassermann  reaction 
with  the  absence  of  any  other  etiological  factor. 

In  most  of  these  patients  the  body  is  stunted  and  ill-formed,  the 
child  has  been  backward  in  walking  and  talking  (one  of  my  cases . 
did  not  speak  at  all  until  the  ninth  year),  and  some  amount  of 
mental  deficiency  will  usually  have  been  apparent  from  the  first 

*  See  a  very  interesting  series  of  articles  by  Dr.  S.  A.  Owen  on  "jSyphilis 
of  the  Nervous  System  in  Infancy,  Childhood,  and  Early  Adult  Life,"  Clinical 
Journal,  1912  ;  also  the  researches  referred  to  in  Chapter  III.,  p.  48. 


268     Secondary  Amentia  and  its  Clinical  Varieties 

few  years  of  life.  As  a  rule  this  is  of  a  comparatively  mild  degree, 
most  of  the  cases  being  merely  feeble-minded  or  high-grade 
imbeciles.  They  go  to  school,  but  make  no  progress,  and  upon 
leaving  they  are  found  incapable  of  following  any  constant  employ- 
ment. Occasionally  the  mental  status  is  that  of  idiocy;  but  up 
to  the  age  of  twelve  to  fifteen  years  the  syphilitic  ament,  beyond 
the  presence  of  the  typical  lesions,  presents  no  special  mental 
pecularities  which  distinguish  him  from  an  ordinary  ament  of 
similar  degree. 

About  or  shortly  after  the  usual  age  of  puberty,  however,  a 
considerable  number  of  these  persons  undergo  a  remarkable  change. 
It  is  noticed  that  the  patient  is  becoming  restless  and  troublesome. 
Hallucinations  and  delusions  often  make  their  appearance,  and  in 
some  cases  there  is  pronounced  mania  or  melancholia.  Soon  after 
this  the  balance  and  gait  of  the  body  become  markedly  unstead}/, 
there  is  considerable  tremor  of  the  hands,  mouth,  and  tongue,  and 
the  speech  becomes  slurred,  indistinct,  and  hesitating.  The  knee- 
jerks  are  increased,  and  ankle  clonus  is  often  found.  Sight  and 
hearing  are  impaired,  and  if  the  eyes  be  examined,  the  pupils  will 
be  seen  to  be  dilated  and  to  react  sluggishly  to  light;  at  a  later 
stage  they  become  fixed.  These  changes  are  followed  by  a  marked 
mental  impairment,  and  the  patient  ceases  to  take  any  interest  in. 
his  surroundings.  There  is  no  remission,  and  time  only  results 
in  an  aggravation  of  all  these  symptoms.  The  body  begins  tO' 
waste,  swallowing  becomes  difficult,  and  the  patient  gets  dirty  in 
his  habits.  With  the  emaciation  there  is  often  considerable  trophic 
disturbance,  so  that  sores  appear.  Finally  he  becomes  bedridden,, 
gradually  sinks  into  a  comatose  state,  and  dies.  In  males  the 
external  genitals  retain  their  infantile  condition,  and  in  females 
menstruation  does  not  appear.  I  have  never  noticed  any  grandiose 
ideas  in  these  persons;  but  convulsive  seizures  are  common,  and 
these  are  occasionally  followed  by  transient  paraylsis.  The  average 
length  of  time  from  the  onset  of  these  symptoms  to  the  end  is 
about  five  years. 

It  is  seen  that  the  symptoms  and  course  of  this  progressive 
degeneration  are  practically  identical  with  those  of  juvenile  general 
paralysis,  and  this  is  further  shown  by  the  post-mortem  appearances. 
In  four  cases  which  I  have  examined  post-mortem  the  brain  was 
small  and  simply  convoluted  as  well  as  wasted,  the  pia-arachnoid 
thickened  and  opaque,  and  the  cerebro-spinal  fluid  in  considerable 


Syphilitic   Amentia  269 

excess.  There  were,  however,  no  gross  syphihtic  lesions.  Micro- 
scopical examination  showed  many  cells  in  a  typical  condition  of 
incomplete  development,  but  over  and  beyond  this  there  were 
extensive  degenerative  changes  indistinguishable  from  those 
occurring  in  general  paralysis.* 

I  do  not  think  that  this  is  the  termination  of  every  case  of 
syphilitic  amentia,  for  I  have  seen  a  few  of  these  patients  who,  at 
over  thirty  years  of  age,  showed  no  mental  or  physical  alteration 
apart  from  the  original  deficiency.  But  although  I  have  made 
diligent  search,  these  latter  cases  are  comparatively  rare,  and  I 
am  inclined  to  think  that  progressive  deterioration,  ending  in 
paralytic  dementia,  is  the  rule  in  amentia  due  to  syphilis. 

The  Diagnosis  of  syphilitic  amentia  rests  upon  the  presence  of 
the  typical  lesions,  or  a  positive  Wassermann  reaction,  plus  amentia, 
in  the  patient.  In  one  of  my  cases  the  signs  were  indefinite,  but 
the  patient's  mother  had  died  of  general  paralysis.  In  another 
case  a  history  was  present,  but  no  marks  could  be  discovered  upon 
the  patient ;  a  brother,  however,  presented  the  characteristic  signs. 
Both  these  cases  were  considered  to  be  probably  syphilitic,  and 
they  subsequently  developed  general  paralysis.  Diagnosis  at 
times,  therefore,  must  be  a  matter  of  uncertainty.  It  need  hardly 
be  emphasized  that  all  subjects  of  congenital  syphilis  do  not  suffer 
from  mental  deficiency ;  on  the  contrary,  the  proportion  who  become 
aments  is  probably  small,  and  it  seems  likely  that  in  most  of  these 
cases  the  arrest  of  mental  development  is  as  much  a  consequence 
of  morbid  heredity  as  of  the  syphilitic  virus,  since  such  heredity, 
or  some  potent  predisposing  cause,  is  present  in  the  majority  of 
cases.  Given  a  child  with  congenital  syphilis,  who  is  at  the  same 
time  the  offspring  of  a  neuropathic  or  degenerate  stock,  then  I 
think  that  amentia  is  extremely  likely  to  result. 

It  has  been  stated  by  Hirsch  that  all  individuals  suffering  from 
juvenile  general  paralysis  have  previously  been  of  feeble  intellect. 
With  this,  however,  I  cannot  agree,  as  I  have  known  several  such 
patients  whose  mental  condition  has  been  quite  up  to  the  normal 
prior  to  the  onset  of  the  degenerative  changes.  But  juvenile 
general  paralytics  who  are  seen  in  the  consulting-room  or  asylum 
in  the  early  stages  of  their  disease  are  often  thought  to  be  imbeciles, 

*  For  one  of  the  best  accounts  of  the  histology  of  juvenile  general  paralysis, 
as  shown  by  modern  methods  of  staining,  see  that  by  Watson  in  Mott's 
"  Archives  of  Neurology,"  vol.  ii.,  p.  621.  Three  at  least  of  the  twelve  cases 
there  recorded  were  aments. 


270     Secondary  Amentia  and  its  Clinical  Varieties 

and  I  have  frequently  known  such  sent  to  training  institutions. 
Inquiries  as  to  the  previous  mental  status,  with  a  careful  examina- 
tion of  the  patient,  should  readily  distinguish  between  the  two 
conditions. 

Prognosis. — In  view  of  the  liability  of  these  patients  to  develop 
general  paralysis,  it  is  obvious  that  a  most  guarded  opinion  must 
be  given  regarding  the  ultimate  prospects  of  improvement  from 
training  in  any  case  of  amentia  which  is  considered  to  be  syphilitic. 
Progressive  dementia  does  not  always  result,  but  it  does  certainly 
appear  to  be  extremeh'  common;  and  antis5''philitic  treatment  has 
been  found  to  have  not  the  slightest  effect  upon  either  the  degenera- 
tion or  the  initial  mental  deficiency. 

Several  of  these  cases  will  be  described  under  General  Paralysis 
in  the  chapter  on  Insane  Aments.  The  following  are  additional 
examples : 

Syphilitic  Amentia  passing  into  Dementia  {probably  General 
Paralysis). — A.  A.,  male.  Insane  heredit}'  on  paternal  side,  but 
no  history  of  syphilis  obtainable,  although  the  patient  has  several 
characteristic  syphilitic  lesions.  He  was  noticed  to  be  backward 
from  birth,  and  did  not  talk  until  eight  3'ears  old.  Went  to  school, 
but  could  never  learn,  and  when  he  left,  at  the  age  of  twelve,  he 
was  only  in  the  second  standard.  He  had  fits  between  six  and 
seven  years  of  age,  which  continued  occasionally  until  fourteen 
years,  and  then  ceased.  No  employment.  Became  unmanageable, 
and  was  sent  to  an  imbecile  institution  when  aged  seventeen.  Re- 
mained there  for  two  years,  but  made  no  progress,  and  was  trans- 
ferred to  an  asylum.  He  gradually  become  paretic  and  tremulous, 
with  small  pupils,  which  scarcely  reacted  to  light.  At  the  present 
time  (aged  twenty)  he  is  ver}-^  simple,  and  answers  questions  in 
a  slow,  m^onotonous,  and  trembling  manner.  He  cannot  do  the 
simplest  sums,  and  does  not  know  how  many  pennies  there  are  in 
sixpence.  There  is  undoubtedly  considerable  mental  deterioration 
in  addition  to  the  original  defect,  and  it  is  probable  that  general 
paralysis  is  supervening. 

Syphilitic  Amentia  icitli  Progressive  Dementia. — S.  G.,  male. 
No  relatives .  living,  and  no  history  or  particulars  ascertainable 
beyond  the  fact  that  he  had  lived  in  imbecile  institutions  since 
the  age  of  nine  3-ears.  In  January,  1895,  at  the  age  of  nineteen 
years,  he  became  violent  and  unmanageable,  attacked  the  atten- 
dants, and  threatened  to  cut  his  throat;  he  was  accordingly  trans- 
ferred to  a  lunatic  asylum.     On  admission  he  was  found  to  be  an 


Plate  XX. 


To/ace  J>agc  270.] 


Syphilitic  Amentia  271 

imbecile  with  aural  hallucinations  and  mild  mania.     He  said  that 
voices  spoke  to  him  and  told  him  to  cut  his  throat.     Many  typical 
marks  of  congenital  syphilis  were  present,  and  he  had  a  habit  of 
constantly  keeping  his  mouth  tightly  closed  in  a  fatuous  grin,  at 
the  same  time  breathing  noisily  through  his  nose.     (See  Plate  XX., 
Fig.  49.)     He  remained  in  practically  the  same  condition  for  the 
next  five  years,  at  times  being  depressed  and  lachrymose,  at  others 
noisy  and  troublesome;  he  was,  however,  clean  in  habits,  and  was 
capable  of  doing  everything  for  himself.     In  December,  igoo,  at 
the  age  of  twenty-four  years,  he  began  to  show  signs  of  dementia, 
becoming  stolid  and  indifferent  to  his  surroundings,  and  frequently 
wet   and  dirty.     The  knee-jerks  were  greatly  exaggerated.     The 
dementia  gradually  became  more  marked,  his  gait  became  shuffling 
and  unsteady,  and  the  knee-jerks  could  not  be  obtained.     During 
the  year  1902  he  began  to  show  marked  bodily  enfeeblement,  the 
dementia  still  continuing  to  progress.     In  February,   1904,  pul- 
monary tuberculosis  was  diagnosed;  it  advanced  with  great  rapidity, 
and  he  died  the  following  month  at  the  age  of  twenty-eight  years. 
There    had    never    been    convulsions    or    seizures.     Post-mortem 
examination  revealed  a  wasted  brain  presenting  the  usual  features 
of  chronic  dementia,  but  none  of  the  particular  signs  of  general 
paralysis.     Its  weight  was  1,100   grammes.     There  was  extensive 
tuberculosis  of  both  lungs. 

Syphilitic  Amentia  passing  into  Dementia* — Family  History. — 
The  father  has  had  syphilis;  a  brother  of  the  patient  also  has 
"  tremblings  ";  no  further  details  obtainable. 

Clinical. — The  patient  was  always  a  quiet  lad,  and  did  not  seem 
so  bright  as  the  other  children.  At  the  age  of  six  years  he  began 
to  show  definite  ataxic  symptoms  (said  to  have  been  caused  by 
a  fright),  chiefly  marked  in  the  legs.  There  was  no  actual  loss  of 
power  complained  of,  but  he  was  only  able  to  stand  with  the  feet 
apart,  and  was  very  unsteady  and  apt  to  fall  whilst  walking;  the 
knee-jerks  were  absent  on  both  sides,  the  pupils  were  widely  dilated, 
considerable  tremor  of  the  eyelids  was  present,  and  there  was 
occasional  incontinence  of  urine.  The  patient  gradually  became 
worse,  eventually  becoming  almost  completely  powerless  and  help- 
less in  bed,  and  quite  demented:  he  died  at  the  age  of  eight  years. 

Upon  making  a  microscopical  examination,  I  found  imperfect 
development  and  irregular  arrangement  of  the  small  and  medium- 

*  For  the  clinical  notes  and  the  central  nervous  system  of  this  case  I  am 
indebted  to  Dr.  F.  J.  Smith,  Physician  to  the  London  Hospital. 


272     Secondary  Amentia  and  its  Clinical  Varieties 

sized  pyramidal  cells  of  the  cerebral  cortex,  indicating  a  condition 
of  mUd  imbecility.  In  addition  there  was  a  subacute  degenera- 
tion affecting  a  large  number  of  these  cells,  and  to  a  less  extent 
those  of  the  anterior  horns  of  the  spinal  cord;  there  was  also  a 
somewhat  more  chronic  degeneration  of  the  cells  and  fibres  of  the 
pyramidal  tract,  and  the  vessel  walls  generally  were  slightly  thick- 
ened. I  did  not  see  this  case  during  life,  but  there  are  many 
points  in  both  the  clinical  and  pathological  appearances  which 
suggest  that  this  degenerative  process  which  was  superadded  to 
the  mUd  amentia  was  analogous  to,  although  not  identical  with, 
that  of  juvenile  general  paralysis. 

AMAUROTIC  FAMILY  IDIOCY,  OR  INFANTILE  CEREBRAL 
DEGENERATION. 

This  disease  is  invariably  fatal,  and  its  subjects  rarely  survive 
sufficiently  long  to  become  candidates  for  a  special  institution  for 
the  mentally  deficient;  but  as  it  is  one  in  which  arrested  cerebral 
development  is  a  prominent,  although  incidental,  feature,  and  as 
on  this  account  it  might  be  confounded  with  the  more  ordinary 
forms  of  amentia,  it  is  necessary  to  allude  to  it. 

The  earliest  account  we  have  is  that  given  by  Mr.  Waren  Tay 
in  1881,  whose  description  chiefly  referred  to  the  peculiar  ocular 
conditions.  In  1887  Dr.  B.  Sachs,  of  New  York,  described  the 
changes  in  the  brain  in  a  paper  entitled  "  Arrested  Cerebral  De- 
velopment." Other  descriptions  have  been  given  by  Goldzicher, 
Magnus,  Knapp,  Wadsworth,  Hirschberg,  Carter,  Hirsch,  Petersen, 
and  Burnet.  The  most  complete  accounts  are  those  of  Kingdon 
and  Risien  Russell,*  which  appeared  in  1897;  of  B.  Sachs, f  in 
1903;  and  of  Poynton,  Parsons,  and  Holmes  J  in  1906;  but  the 
literature  on  this  subject  is  now  very  extensive. 

Infantile  cerebral  degeneration  is  a  disease  which  usually  attacks 
more  than  one  child  of  the  same  family,  and  it  was  formerly  thought 
to  be  restricted  to  Jews;  but  cases  have  recently  been  described 
affecting  Gentiles  and  occurring  at  a  much  later  age  than  those 

*  E.  C.  Kingdon  and  J.  S.  Risien  Russell,  "  Infantile  Cerebral  Degenera- 
tion," Medico-Chirurgical  Transactions,  vol.  Ixxx.,  1897.  This  paper  gives 
a  full  account  of  the  clinical  and  pathological  conditions,  together  with  a 
bibliography  of  the  subject. 

•f  B.  Sachs,  "  On  Amaurotic  Family  Idiocy,"  Journal  of  Nervous  and 
Mental  Disease,  January,  1903. 

X  Poynton,  Parsons,  and  Holmes,  Brain,  June,  1906. 


Amaurotic  Family  Idiocy  273 

noted  by  the  original  authors,  and  it  seems  probable  that  we  shall 
have  to  modify  the  early  views  regarding  Tay-Sachs'  disease,  and 
admit,  with  Vogt,*  that  there  are  two  distinct  forms  of  this  affection, 
one  of  which,  commencing  in  infants,  presents  the  features  to  be 
immediately  described;  whilst  the  other,  the  juvenile  form,  first 
shows  itself  several  years  later,  runs  a  slower  course,  is  not  charac- 
terized by  the  cherry-red  spot  in  the  optic  disc,  and  is  not  so  closely 
confined  to  the  Hebrew  race.  Examples  of  this  latter  variety  have 
been  described  by  Jansk^^  Sachs,  and  others,  and  Karl  Schafferf 
gives  a  very  full  account  of  one  such  patient,  a  low-grade  idiot, 
who  lived  to  the  age  of  twenty-four  years.  Turner J:  has  also 
recently  described  two  patients,  one  aged  fourteen,  and  the  other 
over  five  years.  Male  and  female  children  are  equally  liable  to 
be  affected,  but  no  particular  exciting  or  predisposing  factor  has 
yet  been  discovered.  There  is  no  regularity  in  the  order  in  which 
children  of  the  same  family  are  affected.  It  may  be  the  earlier, 
later,  or  intermediate  children,  the  rest  remaining  perfectly  healthy. 
Kingdon  and  Russell  describe  the  symptoms  and  progress  of  the 
infantile  form  of  the  disease  in  three  stages  as  follows : 

First  Stage. — An  infant,  the  subject  of  this  disease,  is  born  at 
the  full  time  of  gestation,  and  may  be  well  formed  and  developed, 
differing  in  no  outward  respect  from  a  healthy  child,  until  about 
the  completion  of  the  third  month.  At  this  time  some  weakness 
of  the  muscles  of  the  back  and  neck  is  observed,  and  often  a  sus- 
picion that  the  child  sees  imperfectly  is  entertained.  Should  the 
eyes  be  examined  with  the  ophthalmoscope  about  the  fourth  or 
iifth  month,  there  will  be  found  symmetrical  changes  in  the  macula 
lutea,  consisting  of  a  whitish-grey  patch,  somewhat  oval  in  shape 
(the  axis  being  horizontal),  with  softened  edges  slightly  raised 
above  the  general  surface  of  the  retina.  In  the  centre  of  this  patch 
is  seen  the  fovea  centralis  as  a  dark  cherry-red  spot.  These  changes 
in  the  macula  remain  unaltered,  and  are  regarded  as  absolutely 
pathognomonic.  At  a  somewhat  later  course  of  the  disease  there 
is  definite  optic  atrophy  and  total  amaurosis. 

In  the  Second  Stage  the  child  is  unable  to  sit  up;  its  head  falls 
^backwards  if  unsupported;  when  lying  on  its  back  it  is  unable  to 
turn  over  to  either  side.  Objects  placed  in  its  hands  are  grasped 
but  feebly,  and  soon  dropped.     It  is  generally  apathetic,  taking 

*  H.  Vogt,  "  tjber  familiare  amaurotische  Idiotie,"  Monatsschr.  f.  Psychiat. 
u.  Neurolog.,  Band  xviii. 

t   K.  Schaffer,  Archiv  filr  Psychiat.,  Heft  i.,  Band  xlii. 

t   J.  Turner,  Bvitish  Journal  of  Children' s  Diseases,  Ma^',  1912. 


274     Secondary  Amentia  and  its  Clinical  Varieties 

no  notice  of  surrounding  objects,  and  the  face  bears  an  expression 
of  mental  enfeeblement.  Vision  is  reduced  to  perception  of  light, 
but  the  sense  of  hearing  is  acute,  and  remains  so  during  life,  any 
sudden  sound  causing  the  child  to  start.  The  sense  of  taste  i& 
also  preserved. 

In  the  Third  Stage  atrophy  of  the  enfeebled  muscles  ensues,  and  . 
soon  those  of  the  whole  body  are  involved.  Emaciation  progresses, 
and  becomes  most  marked.  The  deep  reflexes  are  exaggerated, 
and  still  later  in  the  course  of  the  disease  rigidity  of  the  extremities 
and  retraction  of  the  head  become  prominent  features;  occasional 
spasmodic  contractions  cause  the  child  to  start  and  cry  from  pain. 
Convulsions  have  been  noted  in  one  or  two  instances  during  the 
course  of  the  disease,  but  they  would  appear  to  be  an  accidental 
accompaniment,  and  are,  at  all  events,  not  the  rule.  The  tempera- 
ture remains  normal  throughout  the  course  of  the  disease.  The 
heart,  lungs,  and  abdominal  viscera  are  also  normal. 

The  duration  of  life  varies  from  one  and  a  half  to  two  and  a  half 
years,  but  is  usually  less  than  two  years,  and  the  disease  is  in- 
variably fatal.  The  essential  pathological  lesion  would  appear  to 
be  a  primary  degeneration  of  the  cortical  neurones,  the  optic  nerves, 
and  the  pyramidal  tracts  throughout  their  whole  course  in  the 
pons,  medulla,  and  spinal  cord.  The  nature  of  the  lesions  and  the 
general  clinical  course  would  suggest  that  the  cause  is  some  circu- 
lating toxin,  but  hitherto  none  such  has  been  discovered,  and  the 
application  of  Wassermann's  reaction  by  Poynton*  failed  to  give 
a  positive  result,  thus  showing  the  absence  of  syphilis.  Dr.  Gordonf 
suggests  that  the  origin  of  the  disease  may  lie  in  some  glandular 
defect  or  anomaly  in  consequence  of  which  a  profound  failure  of 
metabolism  occurs;  but  the  whole  subject  is  still  shrouded  in 
mystery.  I  am  disposed  to  think  that  some  of  the  pivenile  cases 
of  this  disease  which  have  been  described  may  really  have  been 
cases  of  general  paralysis. 

Section  II. 

AMENTIA  DUE  TO  DEFECTIVE  CEREBRAL  NUTRITION. 

Mental  growth  takes  place  as  a  result  of  two  factors.  Firstly, 
the  embryonic  neuroblasts  must  have  within  them  a  capacity  for 
developing  and  acquiring  certain  functional  connexions.     Secondly, 

*  Poynton,  British  Medical  Journal,  May,   1909. 
t  Gordon,  New  York  Medical  Journal,  Ixxxv.,  1907. 


Epileptic  and  Eclampsic  Amentia  275 

they  must  be  supplied  with  food  adequate  in  quantity  and  quality, 
and  they  must  also  be  stimulated  by  impressions  from  without 
reaching  them  through  the  avenues  of  special  sense.  If  either  of 
these  second  essentials  to  growth  be  absent  or  diminished,  mental 
development  may  be  so  interfered  with  that  a  condition  of  amentia 
results,  and  this  is  conveniently  termed  "amentia  due  to  defective 
cerebral  nutrition."  Of  the  type  which  is  due  to  quantitative 
or  qualitative  changes  in  the  blood,  cretinism  is  the  best,  as  well 
as  most  common,  example.  The  variety  due  to  defective  stimula- 
tion is  known  as  "  amentia  due  to  isolation  or  sense  deprivation." 
For  reasons  which  I  have  already  given  on  p.  96,  "  epileptic 
amentia  "  will  also  be  included  in  this  section. 

EPILEPTIC  AND  ECLAMPSIC  AMENTIA. 

It  used  to  be  the  custom,  in  describing  the  varieties  of  amentia, 
to  group  together  into  one  class  all  those  persons  who  were,  or 
had  been,  subject  to  epileptic  or  similar  convulsions,  and  to  label 
them  "  epileptic  "  or  "  eclampsic  "  aments.  A  close  examination 
of  this  class,  however,  shows  that  it  is  really  a  most  heterogeneous 
collection. 

It  is,  perhaps,  not  unnatural  that  the  parents  should  see  in 
convulsions  the  reason  and  cause  of  the  mental  deficiency  of  their 
child,  and,  as  a  matter  of  fact,  there  is  no  other  single  etiological 
factor  which  is  so  frequently  advanced  as  the  "cause."  To  the 
lay  mind  "  fits  "  are  both  impressive  and  alarming.  It  is  not  sur- 
prising that  even  medical  practitioners  should  frequently  be  satis- 
fied with  this  explanation,  for  they  are  fully  aware  of  the  mental 
hebetude  and  degeneration  which  may  supervene  upon  epilepsy. 
But  I  am  convinced,  from  the  examination  of  some  hundreds  of 
aments  suffering  from  epilepsy,  as  well  as  from  careful  inquiries 
into  their  family  and  previous  personal  history,  that  in  the  great 
majority  no  such  causal  relationship  exists  as  is  implied  by  the 
term  "  epileptic  amentia." 

The  relationship  existing  between  epilepsy*  and  amentia  is  of 
three  kinds,  as  follows: 

I.  Primary  Amentia  in  which  Epilepsy  occurs  as  a  Complication 
— This  has  already  been  considered  in  the  chapter  dealing  with 
the  complications  of  primary  amentia  (p.  221). 

*  For  convenience,  the  term  "  epilepsy  "  is  here  used  to  include  epilepti- 
form as  well  as  epileptic  (idiopathic)  convulsions. 


276     Secondary  Amentia  and  its  Clinical  Varieties 

2.  Idiopathic  Epilepsy  or  Eclampsia  causing  Amentia. — It  is 
with  this  group  that  the  present  account  deals. 

3.  Gross  Cerebral  Lesions  causing  Epilepsy  and  Amentia. — Here 
both  the  epilepsy  and  amentia  are  symptomatic  of  brain  lesions 
which  have  already  been  described  in  preceding  pages  (p.  225). 

The  following  table  shows  the  chief  points  of  difference  between 
these  three  groups  in  which  amentia  and  epilepsy  coexist : 

TABLE  XV. 

Showing  the  Relation  of  Epilepsy  to  Amentia. 


Morbid  heredity 

Condition  of 
patient  be- 
fore ttie  fits 


Nature  of  fits 


Condition  of 
patient  after 
fits  have 
made  their 
appearance 


Stigmata  of 
degeneracy 

Prospects  of 
improvement 
under  special 
training 


Group  i. 
Epilepsy  complicating 


Pronounced 

Some  degree  of 
amentia  or  general 
backwardness  usu- 
ally noticed 


Epileptic.  Usually 
milder  and  less  fre- 
quent than  Group  2 


Degree  of  amentia 
often  much  greater 
than  would  be  ac- 
counted for  by  the 
severity  and  fre- 
quency of  fits 

Paralysis  may  be  pre- 
sent also  if  a  gross 
lesion  coexists 

Marked  (except  in 
highest  grades) 

Dependent  upon  se- 
verity and  fre- 
quency of  fits,  but 
on  the  whole  better 
than  in  Groups  2 
and  3 


Group  2. 
Idiopathic  epilepsy 
causing  secondary 
amentia. 


Less  pronounced 
Normal 


Group  3. 

Gross  lesions  causing 

epilepsy  and  secondary 

amentia. 


Absent 

Normal.  Onset  of  fits 
can  generally  be 
traced  to  some  defi- 
nite morbid  process 
affecting  brain 


EpUeptic.    Severe  j  Epileptic.       Occasion- 
and  frequent  ally    epileptiform; 

rarely     constant, 
rhythmic  tremor 

Amentia     usually   Considerable    amentia 

mild,    but   much      may  be  present  with 

dementia  '    mild   and   infrequent 

i    fits 


No  paralysis 


SUght 


Practically  none 


Paralysis  often  present 


Absent 


Dependent  upon  time 
of  occurrence,  site, 
extent,  and  nature  of 
lesion,  and  upon  se- 
verity and  frequency 
of  fits.  Usually  in- 
termediate between 
Groups  I  and  2. 


Epileptic  Amentia. — I  shall  restrict  this  term  to  cases  of  secondary 
amentia  which  are  caused  by  epilepsy.  It  is  common  knowledge 
that  frequently  repeated  convulsions,  or  even  attacks  of  petit  mal. 


Epileptic  and  Eclampsic  Amentia  277 

may  induce  dementia  in  a  person  of  mature  cerebral  development. 
This  result,  however,  is  not  invariable,  as  is  proved  by  many  well- 
known  instances  to  the  contrary.  Thus  Plutarch  says  of  Julius 
Caesar:  "  He  was  of  a  slender  make,  fair,  of  a  delicate  constitution, 
and  subject  to  violent  headaches  and  epileptic  fits."  Mohammed 
was  liable  to  frequent  "  swoons,"  which  were  probably  epileptic 
in  origin.  Napoleon  and  Peter  the  Great  were  also  epileptics. 
Nevertheless,  a  progressive  dementia  is  a  very  frequent  result  of 
this  condition.  The  anatomical  basis  of  this  dementia  is  a  degenera- 
tion of  the  same  cortical  cells  as  are  imperfectly  developed  in 
amentia.*  If  the  development  of  these  neurones  is  as  yet  incom- 
plete, as  in  the  infant,  it  may  be  irremediably  arrested,  and  a 
condition  of  secondary  mental  deficiency  result.  For  the  pro- 
duction of  amentia,  then,  in  addition  to  the  factors  which  produce 
dementia,  the  convulsions  must  occur  during  the  first  few  years  of 
life.  This  is  the  case  in  a  considerable  proportion  of  epileptics,  and 
Sir  William  Gowersf  states  that  in  12-5  per  cent,  of  cases  the  con- 
vulsions make  their  first  appearance  before  the  age  of  three  years.. 
In  such  cases  the  mental  development  of  the  patient  may  become 
arrested,  so  that  whilst  his  body  develops  his  mind  is  no  more 
advanced  than  that  of  an  idiot,  imbecile,  or  feeble-minded  person. 
Sir  George  Savage  makes  the  statement  that  epilepsy  "  occurring 
before  seven  years  of  age  is  certain  to  leave  the  patient  weak- 
minded."  Doubtless  this  is  true,  but  the  "  weak-mindedness  "  is 
not  necessarily  so  severe  as  to  justify  the  term  "mental  deficiency  " 
in  the  sense  in  which  it  is  here  used;  although  some  degree  of 
impairment  does  certainly  result  in  most  cases  of  epilepsy  be- 
ginning thus  early.  The  proportion  of  aments  who  owe  their 
condition  to  this  cause,  however,  and  who  are  truly  sufferers  from 
epileptic  amentia,  is  a  small  one.  In  my  own  series  of  cases  I  find 
that  3*5  per  cent,  only  of  aments  belong  to  this  variety,  but  this 
number  must  be  regarded  as  merely  an  approximate  estimate. 
The  pathology  of  these  cases  has  already  been  described  in  Chap- 
ter IV.;  it  is  usually  that  of  arrested  neuronic  development  plus 
degeneration. 

Epileptic  aments  differ  considerably  in  their  clinical  features. 
In  some  the  bodily  condition  is  sufficiently  unlike  to  be  readily 

*  This  has  been  shown  in  J.  S.  Bolton's  exhaustive  work,  "  Amentia  and 
Dementia,"  Journal  of  Mental  Science,  1905  et  seq. 

f  W.  R.  Gowers,  "  Epilepsy,"  Clifford  AUbutt's  "  System  of  Medicine,'' 
vol.  vii. 


278      Secondary  Amentia  and  its  Clinical  Varieties 

distinguishable  from  ordinary  primary  aments ;  but  there  are  others 
who  resemble  that  class  so  closely  that  a  diagnosis  can  only  be 
made  by  most  careful  attention  to  the  history  and  the  capacity 
of  the  patient  prior  to  the  onset  of  the  fits.  It  may  be  stated  that, 
as  a  general  rule,  epileptic  aments  are  better  grown  and  developed, 
and  possess  fewer  of  the  stigmata  which  are  such  a  conspicuous 
feature  of  the  primary  group. 

The  degree  of  mental  deficiency  varies  from  a.  mild  amount  of 
feeble-mindedness  to  a  state  resembling  idiocy;  but  this  latter 
condition  is  more  often  the  result  of  a  superadded  dementia  than 
of  a  pure  mental  arrest.  In  the  milder  cases,  although  the  patients 
rarely  make  much  headway  with  school  learning,  a  certain  amount 
of  manual  training  is  possible,  and  many  of  them  are  able  to  do 
more  or  less  useful  work.  But  the  persistence  of  the  fits  gradually 
strips  these  persons  of  any  acquirements  they  may  have  possessed, 
and  in  the  majority  of  cases  dementia  is  but  a  question  of  time. 
On  the  whole,  it  may  be  said  that  the  prospects  of  amelioration 
by  training  and  the  general  prognosis  of  this  class  are  of  the  most 
unfavourable  description.  There  are  a  few  cases  of  epileptic 
amentia  in  which  the  fits  cease,  and  in  these  the  mental  condition 
may  improve  very  considerably.  There  are  other  cases  in  which 
a  diminution  of  the  fits  and  some  degree  of  mental  improvement 
takes  place,  apparently  in  consequence  of  medicinal  treatment  and 
regimen;"  but  these  cases  are  decidedly  exceptional,  and  in  no 
instance  is  real  mental  deficiency,  once  produced,  ever  overcome. 

There  is  one  mental  feature  which  is  common  to  most  of  these 
cases,  and  that  is,  a  general  irritability  and  intractability.  Epi- 
leptic aments  are  often  exceedingly  stubborn  and  difficult  to 
manage;  they  are  prone  to  sudden  outbursts  of  temper  and  violence, 
and  they  are,  in  fact,  probably  the  most  untrustworthy  of  all  the 
varieties  of  mental  deficiency. 

With  regard  to  the  fits  themselves  there  is  little  to  be  said.  They 
may  be  of  either  the  minor  or  major  variety,  or  of  both.  They 
are  occasionally  preceded  by  a  definite  aura,  or  by  some  recog- 
nizable alteration  in  the  appearance  of  the  patient,  and  they  are 
usually  followed  by  a  varying  period  of  intellectual,  sensory,  and, 
at  times,  motor  exhaustion,  transient  paresis  being  by  no  means 
uncommon.  In  a  certain  number  of  cases  they  seem  to  be  directly 
excited  by  indigestion,  constipation,  undue  excitement,  or  som_e 
determinate  cause;   in   others  they   occur    independently   of   any 


Epileptic  and  Eclampsic  Amentia  279 

ascertainable  factor.  The  frequency  of  some  is  diminished  by 
dieting,  careful  regulation  of  the  daily  life,  and  the  administration 
of  drugs,  of  which  the  most  valuable  are  still  the  bromides.  In 
many  cases,  however,  the  fits  persist  in  spite  of  all  treatment,  and 
hopeless  dementia  results. 

Eclampsic  Amentia. — Instability  of  the  cortical  cells  of  the  brain 
is  a  normal  characteristic  of  infancy  and  is  probably  in  no  small 
measure  due  to  the  rapid  growth  which  takes  place  during  this 
time.  At  the  end  of  the  first  year  the  brain  weighs  three 
times  as  much  as  it  did  at  birth.  As  a  consequence  there  is  no 
doubt  that  the  child  is  much  more  predisposed  to  convulsions  than 
is  the  adult ;  but  although  convulsions  are  exceedingly  common  in 
infancy,  I  am  of  opinion  that  no  ordinary  excitant  will  produce 
them  in  a  healthy  child  of  good  heredity.  Where  they  occur,  there 
is  either  some  special  inherited  predisposition,  or  else  the  natural 
instability  has  been  markedly  exaggerated  by  a  disturbance  of 
cerebral  nutrition  caused  by  bodily  ill-health.  Where  this  special 
predisposition  exists,  such  simple  exciting  factors  as  acute  indiges- 
tion, constipation,  dentition,  or  the  ordinary  febrile  ailments  of 
childhood,  will  suffice  to  determine  convulsions.  Where  no  pre- 
disposition is  inherited,  it  may  be  acquired  in  consequence  of 
anaemia,  malnutrition,  chronic  disturbance  of  the  alimentary  tract, 
and,  above  all,  rickets. 

It  is  thus  seen  that,  theoretically,  infantile  convulsions  fall  into 
two  groups — those  which  are  the  result  of  an  inherited  predisposi- 
tion, and  those  in  which  the  tendency  is  acquired.  The  former 
miust  be  considered  as  undoubtedly  identical  with  idiopathic 
epilepsy,  and  the  fits  often  persist  throughout  life  as  ordinary 
epilepsy;  the  latter  group  may  be  termed  "eclampsic."  But  it 
is  not  uncommon  for  convulsions  which  have  been  looked  upon  as 
simply  eclampsic  to  recur,  and  to  persist  with  all  the  features  of  true 
epilepsy ;  consequently  the  division  between  these  two  conditions  is 
one  which  is  exceedingly  difficult,  and  at  times  impossible,  to  draw.* 

*  It  is  of  interest  to  note  that  Dr.  R.  O.  Moon,  as  a  result  of  his  examination 
of  200  cases  of  convulsions  in  children,  says:  "  I  have  not  been  able  to  find 
any  clear  dividing-line  between  infantile  convulsions  or  eclampsia  on  the  one 
hand,  and  idiopathic  epilepsy  on  the  other.  .  .  .  On  the  contrary,  it  has 
seemed  to  me  that  convulsions  in  early  life  may  shade  off  indefinitely  into 
epilepsy  or  epileptiform  manifestations,  so  that  it  becomes  often  impossible 
to  say  where  the  one  stops  and  the  other  begins." — "  Some  Observations  on 
Convulsions  in  Children,  and  their  Relation  to  Epilepsy  "  {Lancet,  September 
15,  1906). 


2  8o     Secondary  Amentia  and  its  Clinical  Varieties 

The  term  "  eclampsic  amentia/'  should,  of  course,  be  limited  to 
those  cases  of  mental  deficienc}^  which  are  clearly  the  result  of 
simple  infantile  convulsions  due  to  this  acquired  predisposition. 
Although  this  may  happen,  it  is  rare,  and,  in  my  experience,  in  the 
great  majority  of  children  who  thus  suffer  from  a  series  of  fits  which 
do  not  recur,  there  is  no  permanent  impairment  of  the  mental 
faculties. 

Illustrative  Cases. 

L.  J .,  male,  the  fourth  born  of  a  familj'  of  eight,  of  whom  three 
only  are  now  alive;  the  remaining  five  died  in  infancy,  and  all  of 
them  were  subject  to  convulsions.  The  patient's  father  was 
strongly  addicted  to  alcohol,  and  died  at  the  age  of  forty-seven, 
cause  unknown;  his  father's  father  died  aged  fiftj^-seven,  and  was 
paralyzed  for  six  years  before  death.  The  patient's  mother  is  alive 
and  in  tolerably  good  health;  she  had  thirteen  brothers  and  sisters, 
all  of  whom  are  dead,  several  of  consumption,  and  her  father  died 
aged  fifty,  of  asthma. 

The  patient  had  fits  when  a  month  old,  and  they  have  continued 
on  and  off  ever  since.  During  infancy  he  used  to  have  as  many 
as  ten  daily.  With  the  exception  of  the  fits,  he  was  not  noticed 
to  be  different  to  other  children  until  schooHng  began.  He  was 
then  found  unable  to  make  any  progress,  and  after  a  short  time 
was  discharged.  He  remained  at  home  pottering  about,  but  doing 
no  regular  work,  until  seventeen  years  of  age,  when  he  became  so 
unmanageable  that  he  had  to  be  sent  to  an  asjdum.  On  admission 
he  was  a  pale-faced,  somewhat  undersized  youth,  with  slight 
stigmata  of  degeneracy.  He  was  dull  of  comprehension,  and  slow 
in  realizing  what  was  said  to  him.  Memory  very  defective,  and 
in  replying  to  questions  he  would  constantly  repeat  himself.  Able 
to  draw  a  little,  but  unable  to  read,  write,  or  sum,  and  decidedly 
feeble-minded.  He  was  liable  to  attacks  of  violence  before  the 
fits,  and  would  then  attack  anyone  who  might  be  near  him.  After 
the  fits  he  remained  heavy  and  stuporose  for  a  day  or  more.  He 
admitted  that  he  was  excited  before  the  fits,  and  said  it  came  over 
him  "  all  of  a  sudden."  He  complained  a  good  deal  of  headache. 
He  remained  in  practically  the  same  condition,  having  fits  at  the 
rate  of  three  or  four  weekly,  and  being  either  too  excitable  or  too 
stuporose  to  do  any  work.  He  is  now,  at  the  age  of  twenty,  showing 
signs  of  dementia.     (See  Plate  XV.,  Fig.  39.) 


Epileptic  and  Eclampsic  Amentia  281 

F.  S.,  female,  the  eighth  of  a  family  of  thirteen,  three  of  whom 
are  dead,  the  remainder  hving,  and  said  to  be  in  good  health. 
The  father  has  been  insane  in  an  as3dum.  The  patient  had  severe 
fits  whilst  cutting  her  teeth,  and  they  recurred  almost  daily  until 
she  was  five  years  old.  Since  then  they  have  only  returned  at  rare 
intervals.  She  always  seemed  idiotic,  had  no  idea  of  playing  like 
the  other  children,  and  received  no  education  of  any  kind.  She 
remained  at  home  until  in  her  teens,  but  was  a  great  trouble,  being 
unable  to  speak  or  look  after  herself  in  any  way.  She  would 
wander  aimlessly  about  the  house,  and  was  generally  very  restless; 
if  left  alone  would  be  sure  to  get  into  trouble,  and  was  occasionally 
violent  and  aggressive.  She  finally  became  so  unmanageable  that 
she  had  to  be  sent  to  an  asylum. 

On  admission  there  was  a  state  of  amentia  and  dementia  which 
caused  her  to  resemble  a  pronounced  idiot.  She  had  no  under- 
standing of  what  was  said  to  her,  and  was  unable  to  articulate. 
She  spent  the  day  sitting  in  a  chair  rocking  herself  to  and  fro,  and 
occasionally  screaming  or  making  a  grunting  noise.  She  had  no 
idea  of  personal  cleanliness,  and  had  to  be  fed  with  a  spoon.  She 
destroyed  everything  she  could  lay  her  hands  on.  At  the  present 
time  she  is  twenty-seven  years  of  age,  and  her  condition  is  practically 
unchanged.  She  has  had  a  few  epileptic  fits  at  rare  intervals,  the 
longest  period  of  intermission  being  four  years. 

To  these  two  examples  man}^  others  might  be  added,  but  they 
are  sufficient  to  illustrate  the  unfavourable  type  of  amentia  which 
may  result  from  severe  epilepsy  in  early  life.  The  effect,  as  already 
remarked,  is  not  always  so  serious,  and  I  know  several  instances 
in  which  but  a  mild  degree  of  mental  deficiency  has  been  produced , 
and  where  inore  or  less  continuous  occupation  is  possible.  But 
I  think  these  latter  cases  are  exceptional.  There  is  no  doubt  that 
the  prospect  of  improvement  is  greatest  where  the  convulsions 
can  be  relieved  by  treatment,  and  hence  the  importance  of  careful 
medical  supervision  of  these  cases.  Into  the  question  of  treatment 
I  do  not  propose  to  enter,  since  it  is  that  of  ordinary  epilepsy. 
It  may,  however,  be  stated  that  attention  to  the  diet  and  the  ordering 
of  the  daily  life  are  of  the  utmost  importance,  whilst  of  drugs  the 
bromides  will  usually  be  found  the  most  efficacious. 


282     Secondary  Amentia  and  its  Clinical  Varieties 


CRETINISM. 

Although  cretins  have  been  recognized  and  remarked  upon  for 
hundreds  of  years  (even  by  such  ancient  writers  as  Juvenal,  Pliny, 
Strabo,  as  well  as  by  the  more  modern  Paracelsus),  it  is  only  com- 
paratively recently  that  the  cause  of  this  condition  has  been  at  all 
understood.  It  is  now  established  bej^ond  doubt  that  cretinism 
is  closely  allied  to  myxoedema,  and  that  they  are  both  dependent 
upon  an  absence  or  diminished  secretion  of  the  thyroid  gland. 

There  are  two  kinds  of  cretinism — endemic  and  sporadic  ;  and 
although  these  have  much  in  common,  it  is  convenient,  for  purposes 
of  description,  to  consider  them  separately. 

Endemic  Cretinism. — Endemic  cretinism  is  a  disease  of  wide 
incidence.  It  is  most  common  in  Europe,  particularly  in  the 
mountains  and  vaUej's  of  Switzerland  and  the  adjacent  countries; 
but  it  also  occurs  in  the  Himalayas  of  India,  the  Andes  and  Rocky 
Mountains  of  America,  as  well  as  in  Burmah  and  Madagascar.  In 
fact,  there  is  hardly  any  quarter  of  the  globe  which  is  free  from 
this  affection.  In  England  cases  are  occasionally  seen  in  Derby- 
shire and  the  western  portion  of  Yorkshire.  In  Somersetshire  it 
used  to  be  fairly  common,  but  is  not  now  so  frequently  seen.  In 
a  large  number  of  cases  of  the  endemic  form  of  this  disease  a  goitre 
is  present,  but,  although  some  diversity  exists  in  the  mental  and 
bodily  condition  of  the  patients,  the  effect  on  the  whole  seems  to 
be  the  result  of  an  inadequate  and  not  excessive  secretion  of  the 
thyroid  gland. 

As  to  the  cause  of  this  thyroid  anomaly  we  know  very  little, 
but  it  seems  to  be  related  in  some  peculiar  manner  with  the  water- 
supply.  It  is  probable  that  the  future  will  reveal  the  presence  of 
some  specific  microbe  or  virus,  but  hitherto  none  has  been  isolated, 
although  McCarrison,*  in  a  valuable  study  of  endemic  goitre  in 
India,  adduces  strong  evidence  in  favour  of  its  infective  nature, 
and  concludes  that,  although  water  is  the  chief  vehicle  for  the 
organism  of  the  disease,  it  is  not  the  only  one.  Professor  Wilmsf 
also  brings  forward  evidence  to  show  that  a  toxin  is  present  which 
can  be  destroyed  by  heating  the  water,  but  which  is  not  removed 
by  filtration. 

*   R.  McCarrison,  I. M.S.,  Lancet,  December  8,  1906,  p.  1570. 
I  Wilms,  Deutsche  Medizinische  W ochenschy . ,  March,  1910. 


Cretinism  283 

In  consequence  of  this  condition  of  the  thyroid  a  marked  altera- 
tion takes  place  in  the  bodily  and  (usually)  mental  state  of  the 
person  affected.  In  congenital  or  infantile  cases  the  whole  nutri- 
tion of  the  body  is  disturbed.  There  is  a  marked  diminution  in 
the  number  of  red  blood-corpuscles  as  well  as  in  the  percentage 
of  haemoglobin.  The  child,  whilst  usually  remaining  fat  and 
puffy,  makes  very  little  growth,  and  the  majority  of  these  persons 
remain  dwarfs.  The  skin  is  sallow  or  actually  yellow,  dry,  thick- 
ened, and  wrinkled,  and  has  the  appearance  of  being  too  large  for 
the  body.  The  head  is  large  and  the  fontanelles  are  late  in  closing. 
The  nose  is  broad  and  fiat,  the  lips  thick  and  swollen,  and  the 
tongue  so  large  that  it  often  hangs  out  of  the  open  mouth.  The 
belly  is  protuberant,  and  the  lower  limbs  short  and  bowed.  The 
whole  body  is  unwieldy,  its  balance  unsteady,  and  its  gait  ungainly . 
Puberty  is  often  delayed,  and  man}^  pronounced  cretins  are  sterile. 
In  fact,  these  children  as  a  whole  present  bodily  signs  identical  with 
those  of  the  sporadic  variety.  In  those  cases  in  which  the  disease 
is  acquired  in  later  life,  as  a  consequence  of  residence  in  a  goitrous 
locality,  changes  analogous  to  those  occurring  in  myxoedema  are 
produced. 

It  has  been  stated  that  this  condition  of  athyroidea  may  exist 
without  any  mental  change,  and  although  this  may  sometimes  be 
true  where  the  disease  is  acquired  in  later  life,  and  also  in  very 
•exceptional  instances  in  the  congenital  form,  there  is  usually  pro- 
duced some  degree  of  mental  deficiency.  This  ranges  from  a  mUd 
amount  of  feeble-mindedness  to  a  state  of  gross  idiocy,  and  is 
usually  accompanied  by  deafness.  This  latter,  however,  would 
appear  to  be  dependent  upon  the  presence  of  vegetations  blocking 
the  Eustachian  tube,  and  not  upon  any  nerve  change.  The  report 
of  the  Royal  Commission  of  Sardinia*  divides  cretins  into  the 
following  three  classes,  which,  as  will  be  seen,  are  practically 
identical  with  the  three  grades  of  amentia  described  in  this  book 
as  idiocy,  imbecility,  and  feeble-mindedness : 

In  Class  I.  the  subjects  have  only  vegetative  faculties,  are  entirely 
destitute  of  reproductive  and  intellectual  powers,  and  cannot 
speak.     They  are  styled  simply  "  cretins." 

In  Class  II.  they  have  vegetative  and  reproductive  faculties 
and  some  rudiments  of  language.     Their  intellectual  efforts  go  no 

*  For  these  extracts  I  am  indebted  to  the  excellent  account  in  Dr.  Ireland's 
work. 


284     Secondary  Amentia  and  its  Clinical  Varieties 

farther  than  their  bodily  wants,  corresponding  only  to  the  impres- 
sion of  the  senses.     They  are  called  "  semi-cretins." 

In  Class  III.  there  is  added  to  the  faculty  of  the  preceding  one- 
a  greater  amount  of  intellectual  power  without  reaching  the  normal 
human  capacity.  They  have  some  aptitude  at  learning  a  trade 
or  doing  different  kinds  of  work.  They  are  called  "  cretineux,"  or 
"  cretinous." 

Sporadic  Cretinism  (Cretinoid,  MyxoBdematous,  or  Pachydermic 
Amentia). — ^This  condition  was  first  described  by  the  late  Dr.  Hilton 
Fagge  in  1871,  and  although  since  then  a  considerable  number  of 
cases  have  been  reported,  it  is  nevertheless  a  rare  disease.  Cretinoid 
aments  do  not  now  compose  more  than  a  fraction  per  cent,  of  all 
aments,  and  the  proportion  is  steadily  tending  to  diminish  under- 
modern  therapy. 

Although  sporadic  have  many  features  in  common  with  endemic 
cretins,  and  although  in  each  there  is  a  condition  of  athyroidea, 
there  are  some  points  of  difference  between  the  two.  In  the  first 
place,  whilst  a  goitre  is  often  present  in  the  endemic  form,  in  the 
sporadic  cases  the  thyroid  gland  is  usually  entirely  absent.- 
Secondly,  although  the  sporadic  cases  may  occur  in  regions  in: 
which  goitre  is  prevalent,  they  often  crop  up  quite  apart  from  such 
a  condition,  and  in  families  and  localities  in  which  goitre  is  un- 
known. 

Etiology  .—This  raises  the  questions  of  the  cause  of  sporadic 
cretinism  and  its  relation  to  the  endemic  form.  In  a  few  of  the 
cases  coming  under  my  own  observation  I  found  a  marked  neuro- 
pathic family  history,  just  the  same  as  in  ordinary  primary  aments,, 
and  this  led  me  to  make  further  inquiries  on  this  point.  Several 
consulting  physicians,  having  a  considerable  experience  of  cretins, 
and  who  were  good  enough  to  reply  to  my  inquiries,  informed  me 
that  no  special  neuropathic  heredity  had  been  noticed;  but  they 
added  that  the  majority  of  the  patients  had  been  seen  in  hospital 
practice,  and  no  special  attention  had  been  given  to  the  family 
history.  Dr.  John  Thomson  of  Edinburgh,  however,  had  fully 
investigated  the  family  history  in  seventeen  of  his  patients,  with. 
the  following  result:  In  nine  there  was  no  history  of  nervous  or 
mental  disease  or  of  alcoholism;  of  the  remaining  eight,  in  one  a 
brother  and  sister  were  dwarfs,  in  four  there  was  a  family  history 
of  mental  alienation,  and  in  another  of  epilepsy,  whilst  the  fathers 
of  the  remaining  two  patients  were  alcoholic. 


Cretinism  285 

I  am  greatly  indebted  to  Dr.  Thomson  for  his  kindness  in  supply- 
ing me  with  these  details,  which  seem  to  show  that,  although  on 
the  whole  neuropathic  heredity  is  not  a  marked  feature  of  this 
condition,  such  nevertheless  occurs  in  a  proportion  of  cases — that 
it  is,  in  fact,  more  prevalent  in  cretins  than  in  ordinary  persons. 
Whether  in  such  cases  the  absence  of  the  thyroid  gland  should  be 
looked  upon  as  a  peculiar  stigma  of  degeneracy  complicating  primary 
amentia,  or  whether  it  is  that  in  these  cases  the  athyroidea  is  due 
to  the  same  unknown  cause  as  in  the  non-hereditary  cases,  I  am 
unable  to  say.  The  cause  of  sporadic  cretinism  is  shrouded  in 
so  much  mystery  as  to  be  at  present  a  complete  enigma,  and  it 
may  be  a  mere  chance  that  the  neuropath  as  well  as  the  non- 
neuropath  should  be  affected.  However  this  may  be,  it  is  possible 
that  a  neuropathic  inheritance  may  be  not  without  influence 
in  affecting  the  response  to  thyroid  treatment,  which,  although  in 
many  cases  seemingly  dependent  upon  the  age  at  which  it  is  begun, 
is  not  entirely  determined  thereby. 

Pathology. — Whatever  may  be  the  cause  of  the  thyroid  anomaly, 
there  is  not  the  slightest  doubt  that  the  secretion  of  this  gland 
exercises  a  profound  influence  upon  the  nutrition  of  the  brain,  and 
in  most,  if  not  all,  cases  of  cretinism  it  is  clearly  to  the  absence  of 
this  secretion  that  the  mental  peculiarity  is  due.  It  is  of  interest 
in  this  connexion  to  recall  the  state  of  mental  hebetude,  in  some 
cases  amounting  to  dementia,  which  results  in  the  analogous  con- 
dition of  myxoedema  seen  in  adults. 

The  defect  of  this  secretion  does  not  lead  to  any  characteristic 
lesion  of  the  brain.  The  neurones  are  simply  unable  to  develop 
and  to  perform  their  function  because  an  essential  constituent  of 
their  nutriment  is  lacking,  but  superadded  pathological  processes 
probably  occur  in  cases  of  long  standing.  In  several  cases  which 
have  been  examined  after  death,  the  cortical  cells  have  been 
found  in  a  condition  of  incomplete  development,  like  that  already 
described  as  occurring  in  primary  amentia.  Sometimes,  in  addition, 
the  whole  brain  is  found  to  be  small  and  simply  convoluted;  and 
Scholz  and  Zingerle*  have  described  the  presence  of  hydrocephalus, 
various  hemiatrophies  and  asymmetries,  and  areas  of  cortical 
sclerosis. 

Clinical  Symptoms. — The  symptoms  of  sporadic  cretinism  usually 
make  their  appearance  during  the  first  year,  although  they  are 

*  Scholz  and  Zingerle,  Zeiischr.  f.  Heilk.,  1906. 


286     Secondary  Amentia  and  its  Clinical  Varieties 

rarely  noticeable  until  the  sixth  or  seventh  month.  Exceptionally 
they  may  not  occur  until  the  second  or  third,  or  even  sixth  or 
seventh  year,  but  such  cases  are  rare.  The  parents'  attention  is 
generally  first  attracted  by  the  fact  that  the  child  neither  grows 
so  rapidly  nor  appears  as  bright  mentally  as  a  normal  child  of 
corresponding  age;  also,  in  the  cases  with  early  onset,  that  he 
makes  no  attempt  to  sit  up,  to  stand,  or  to  talk.  It  is  commonty 
said  that  the  primary  dentition  is  considerably  delayed,  but  Dr. 
Thomson  doubts  this,  and  he  has  been  good  enough  to  supply  me 
with  details  of  ten  patients  regarding  this  point,  from  which  it 
appears  that,  in  the  absence  of  rickets,  the  time  of  dentition  does 
not  differ  markedly  from  that  of  ordinary  children.  The  anterior 
fontanelle  is  late  in  closing,  and  has  been  observed  open  in  adults. 
Attempts  at  walking  may  not  be  performed  until  the  fifth  year  or 
later.  Speech  may  be  delayed  until  the  seventh  or  eighth  year, 
and  may  never  appear.  Usually  within  a  few  years  after  birth  the 
child  has  assumed  the  characteristic  cretinous  appearance. 

The  characteristic  features  of  the  fully  developed  condition  are 
as  follows:  The  body  is  greatly  dwarfed,  and  many  children  of 
fifteen  or  sixteen  years  of  age  do  not  measure  more  than  3  feet  in 
height.  (The  accompanying  illustrations  (Plate  XXI.,  Figs.  51 
and  52)  show  a  cretin,  aged  thirty-nine,  whose  height  is  only  a 
little  over  3  feet.)  The  head  is  usually  large;  the  legs  are  extremely 
short  and  bowed;  the  hands  and  feet  stumpy  and  ill-formed.  The 
ossification  of  the  bones  is  delayed  considerabty  beyond  the  normal 
period.  The  appearance  of  the  face  alone  is  often  typical,  the 
nose  being  broad  and  flattened,  the  eyes  widely  separated,  the  lips 
thick,  the  mouth  partly  open,  and  the  tongue  thick,  coarse,  and 
protruding.  In  addition,  the  eyelids  are  often  heavy  and  swollen, 
and  the  hair  coarse  and  scanty.  A  very  important  feature  is  the 
skin,  which  is  sallow,  exceedingly  dry,  rough,  and  so  redundant  as 
to  appear  much  too  large  for  the  stunted  bod}-.  Doubtless  this  is 
the  result  of  the  under-development  chiefly  affecting  the  tissues  of 
mesoblastic  origin.  The  neck  is  usually  short  and  thick  and  the 
belly  protuberant.     Umbilical  hernia  is  common. 

Puberty  is  usually  late  in  appearing,  and  the  external  genitals 
often  retain  an  infantile  appearance  until  past  mature  age.  Many 
of  these  patients  are  sterile.  In  the  majority  of  cases  the  thyroid 
gland  is  completely  absent,  and  in  a  considerable  number  of  cases 
there  are  small  soft  swellings  above  the  clavicles  or  in  the  axiUas. 


Plate  XXI. 


To  face  pa^e  286. 


Cretinism  287 

These  are  apparently  fatty,  and  they  disappear  rapidly  under 
thyroid  treatment.  The  pulse  and  respiration  are  slow,  and  the 
temperature  two  or  three  degrees  below  the  normal.  As  a  result 
of  his  examination  of  the  blood,  Vaquez  found  that  there  was  a 
marked  diminution  in  the  number  of  the  red  corpuscles,  as  well 
as  their  contained  haemoglobin,  with  an  excessive  number  of 
nucleated  corpuscles. 

These  children  are  often  voracious  eaters,  but,  although  well 
nourished  and  even  fat,  most  of  them  suffer  from  a  general  mus- 
cular weakness.  This,  together  with  their  mental  torpidity,  causes 
the  bodily  balance  to  be  unsteady,  the  gait  slow  and  waddling, 
and  all  movements  to  be  performed  with  a  laboured  clumsiness. 
These  bodily  peculiarities,  associated  as  they  are  with  their  general 
slothfulness,  apathy,  and  want  of  expression,  produce  a  chnical 
picture  which  can  rarely  be  mistaken. 

MentaUy  these  persons  are  characterized  by  a  general  impair- 
ment of  all  the  faculties.  There  is  often  considerable  defect  in  the 
power  of  hearing,  but  beyond  an  obtuseness  of  perception  there  is 
not  any  other  marked  abnormality  of  the  special  senses.  Some 
of  them  are  pronounced  imbeciles,  or  even  idiots,  but  in  others  the 
degree  of  mental  deficiency  is  one  of  mild  imbecility.  Most  of 
these  milder  cases  can  be  taught  to  read  and  write  simple  words, 
to  count,  to  do  little  sums  in  addition  and  subtraction,  and  to 
perform  small  tasks.  Others,  whilst  capable  of  assisting  in  the 
domestic  work  of  the  institution,  make  absolutely  no  headway 
in  book-learning.  Most  of  them  can  be  taught  to  be  methodical 
and  clean  in  their  habits.  As  a  class  they  are  placid,  harmless, 
good-tempered,  and  affectionate;  and  although  they  show  little 
trace  of  emotion,  they  are  nevertheless  capable  of  being  pleased 
and  amused  in  a  dull,  heavy  sort  of  way.  They  are  amongst  the 
least  troublesome  of  all  aments. 

I  know  of  no  statistics  enabling  the  mortality  of  these  persons 
to  be  compared  with  that  of  ordinary  aments,  but  nty  impression 
is  that  they  are  decidedly  less  frail,  and  not  so  prone  to  early  death. 
Phthisis  does  not  seem  to  be  nearly  so  common.  The  oldest  cretin 
I  know  is  an  imbecile  man  aged  sixty-three  years.  He  is  looked 
after  by  his  sister,  who  keeps  a  small  village  shop,  and  he  is  appar- 
ently in  good  bodily  health.  He  has  never  been  under  thyroid 
treatment. 

Diagnosis.— In   a   well-marked   case   of   sporadic   cretinism   the 


288     Secondary  Amentia  and  its  Clinical  Varieties 

mental  and  bodily  conditions  are  sufficiently  characteristic  to  make 
the  diagnosis  easy.  But  all  cases  are  not  equally  well  marked,  and 
there  are  some  other  diseases  which,  owing  to  certain  points  of 
resemblance,  may  be  thought  to  be  cretinism.  The  converse 
mistake,  except,  perhaps,  in  the  case  of  rickets,  is  less  likely  to  be 
made.  The  chief  of  these  are  rickets,  hydrocephalus,  achondro- 
plasia, hypertrophic  and  Mongolian  amentia. 

1.  Rickets. — It  is  not  uncommon  for  early  cases  of  cretinism  to 
be  called  rickets,  but  the  characteristic  beading  of  the  ribs  and 
symmetrical  enlargement  of  the  epiphyses  in  this  latter  condition, 
with  the  absence  of  the  typical  cretinous  facies,  should  suffice  to 
distinguish  between  the  two. 

2.  Hydrocephalus. — ^The  only  points  in  common  are  the  large 
head,  the  muscular  weakness,  and  the  mental  apathy.  But  the 
enlarged  head  of  the  hydrocephalic  is  totally  different  to  that  of 
the  cretin,  and  the  mental  and  bodily  differences  between  these  two 
conditions  are  much  more  pronounced  than  are  the  resemblances. 

3.  Achondroplasia,  although  very  rare,  is  often  called  cretinism. 
It  is  distinguished  by  the  facts  that,  although  the  child  is  dwarfed 
owing  to  imperfect  development  of  the  long  bones,  and  although 
the  skin  is  often  dry  and  somewhat  redundant,  there  is  a  complete 
absence  of  the  swoUen  eyeUds,  the  broad,  squat  nose,  the  enlarged 
tongue  and  mouth  of  the  cretin.  Moreover,  the  mental  develop- 
ment is'  unaffected,  and  children  suffering  from  achondroplasia  are 
intelligent  and  vivacious. 

4.  Hypertrophic  Aments  resemble  cretins  in  the  large  head  and 
somewhat  stunted  body,  and  the  resemblance  may  be  intensified 
by  the  tottering  gait,  general  muscular  weakness,  and  mental 
inertia.  But  the  facies  of  the  hypertrophic  are  different:  the  skin 
lacks  the  dryness  and  redundancy  of  the  cretin,  and  has  not  the 
same  bogginess;  there  is  as  a  rule  no  delay  in  the  development  of 
puberty,  and  there  is  not  the  same  subnormal  temperature.  More- 
over, the  hypertrophic  ament  complains  of  head  pain,  and  is  often 
subject  to  outbreaks  of  temper  and  excitement  which  are  totally 
foreign  to  the  lethargic,  inert  cretin. 

5.  Mongolian  Aments  are  frequently  thought  to  be  cretins,  and 
were  for  a  long  time  called  "  cretinoids."  The  differential  diag- 
nosis has  been  given  on  p.  220. 

Treatment  and  its  Residt. — That  this  condition  is  the  result  of 
an  absent  or  defective  secretion  of  the  th\Toid  gland  is  full}'  shown 


Cretinism  289 

by  the  remarkable  results  which  follow  thyroid  administration. 
Under  its  influence  the  characteristic  facies  disappear,  the  skin 
becomes  moist  and  supple,  the  body  rapidly  increases  in  growth, 
and  in  many  cases  a  marked  improvement  takes  place  in  the  mental 
condition.  But  to  obtain  this  favourable  result  the  treatment 
must  be  continuous,  and  it  must  be  begun  at  a  sufficiently  early 
age. 

The  effect  of  thyroid  treatment  is  decidedly  more  uncertain  and 
less  pronounced  upon  the  mental  than  the  bodily  development. 
To  a  great  extent  this  appears  to  be  dependent  upon  the  age  at 
which  it  is  commenced,  but  there  may  be  other  factors  which 
influence  the  result.  Dr.  G.  A.  Sutherland  mentioned  to  me  the 
case  of  one  of  his  patients  in  whom  the  disease  was  diagnosed  at 
the  age  of  three  months,  and  who  after  continuous  treatment  for 
six  years  showed  no  mental  impairment.  Dr.  Robert  Hutchison 
tells  me  of  a  case  of  his  which  has  been  treated  from  the  third 
month,  and  now,  at  the  age  of  fifteen  years,  is  apparently  of  normal 
mental  capacity.  Dr.  George  Murray,  of  Newcastle,  has  also  ex- 
perienced such  a  satisfactory  result.  Dr.  John  Thomson  has 
supplied  me  with  particulars  of  a  boy  where  treatment  was  begun 
at  the  age  of  seven  and  a  half  months,  and  who  now,  at  the  age 
■of  eleven  and  a  half  years,  is  so  far  improved  that  he  reads  and 
spells  as  well  as  the  average  of  his  age,  his  only  noticeable  weakness 
being  in  arithmetic.  Another  patient  of  Dr.  Thomson's  was 
started  upon  thyroid  at  the  age  of  seven  and  a  half  weeks,  and  now, 
at  six  and  a  half  years,  is  of  normal  appearance,  somewhat  above 
the  average  height,  and,  although  not  very  energetic,  appears  to 
be  of  normal  intelligence.  Another  case  is  that  of  a  girl  who  has 
been  under  treatment  since  the  age  of  four  years  eleven  months. 
She  reached  the  sixth  standard  at  school,  but  never  did  much  at 
arithmetic.  She  is  now  engaged  as  a  compositor  in  a  printing- 
ofiice,  but,  owing  to  her  slowness  in  lifting  the  type,  only  earns 
half  the  wage  of  other  girls  of  similar  age  doing  the  same 
work. 

It  must  be  admitted,  however,  that  such  cases  are  somewhat  ex- 
ceptional and  not  the  rule,  and  it  is  the  general  experience  of  those 
who  have  knowledge  of  these  persons  that  the  mental  is  rarely 
commensurate  with  the  bodily  development.  I  have  in  my  care 
at  the  present  time  a  patient  who  is  an  excellent  illustration 
of  this  fact.     He  was  sent  to  me  at  the  age    of   eight   years  by 

19 


290     Secondary  Amentia  and  its  Clinical  Varieties 

Dr.  Soltau  Fenwick,  with  a  letter  to  the  effect  that  it  was  a  case  of 
cretinism  which  had  been  under  treatment  since  infancy,  and  had 
improved  wonderfully  in  all  but  the  mental  symptoms.  I  could 
detect  absolutely  no  bodily  sign  of  cretinism,  and,  instead  of  the 
torpid  mental  state  characteristic  of  that  condition,  he  was  alert 
and  active.  But  the  boy  was  a  pronounced  imbecile,  and  he  has 
made  but  little  improvement  under  special  training.  In  this  case 
there  is  marked  neuropathic  heredity,  and  the  mother  has  been 
insane  in  an  asylum.  Dr.  Robert  Hutchison  tells  me  of  a  similar 
case  which  he  has  treated  continuously  since  the  seventh  month, 
and  yet  the  child  is  a  hopeless  imbecile,  although  not  in  the  least 
Hke  a  cretin  in  appearance.  Perhaps  these  instances  represent 
the  opposite  extreme,  for  I  think  it  is  somewhat  unusual  for  mental 
improvement  to  be  so  slight  where  treatment  is  begun  thus  early. 

In  some  patients  improvement  takes  place  at  an  even  later 
age.  Dr.  Caldecott,  of  Earlswood  Asylum,  has  at  the  present 
time  in  his  care  a  cretin  who  was  admitted  at  the  age  of  fourteen 
years.  She  could  not  walk,  talk,  nor  swallow  solid  food,  and  her 
mental  status  was  that  of  a  low-grade  idiot.  She  had  never  been 
treated  with  thyroid.  After  three  years'  treatment  she  has  grown 
12  inches,  can  walk  and  run  about,  talks  fairly  distinctly,  and  is 
taking  her  place  in  school. 

On  the  whole,  I  think  it  may  be  laid  down  that,  whilst  in  some 
cases  Cure  may  take  place  if  treatment  be  initiated  not  later  than 
the  third  month,  should  the  first  year  be  allowed  to  pass  without 
thyroid  administration,  the  cretin,  although  improving  to  some 
extent,  will  seldom  fully  make  up  his  mental  arrears. 

The  most  convenient  method  of  treatment  is  by  means  of  tabloids 
of  the  dried  extract.  Usually  for  a  child  of  from  three  to  six 
months  a  dose  of  |  grain  once  or  twice  daily  will  be  found  appro- 
priate. This  must  be  gradually  increased  at  the  rate  of  i  grain 
per  diem  for  each  year  of  the  child's  age,  with  a  maximum  of 
15  grains.  Treatment  must  be  continued  after  the  symptoms 
have  disappeared,  or  a  relapse  will  ensue;  but  usually  an  occa- 
sional large  dose  is  sufficient  to  maintain  the  effect. 

The  thyroid  must  be  given  cautiously  at  first,  and  the  dose  in- 
creased very  gradually.  In  some  cases  it  causes  diarrhoea,  rise- 
of  temperature,  and  marked  acceleration  of  the  heart,  apparently 
as  a  result  of  the  increased  metabolism.  It  should  then  be  dis- 
continued for  a  time,  and  again  cautiously  resumed.     The  exces- 


Nutritional  Amentia  291 

sive  growth  of  the  long  bones  may  cause  them  to  bend  readily, 
and  in  order  to  prevent  serious  curvatures  movement  must  be 
carefully  supervised. 

In  connexion  with  the  subject  of  cretinism  I  may  mention  the 
following  curious  case  of  temporary  cessation  of  mental  and  bodily 
development  occurring  in  a  girl  at  the  age  of  puberty.  I  have 
never  seen  a  similar  case  described,  and  the  only  explanation  I 
can  suggest  is  that  for  some  reason  or  other  the  secretion  of  the 
thyroid  gland  was  temporarily  suspended.  When  I  first  saw  the 
girl  she  was  seventeen  years  of  age,  but  in  height,  manner,  and 
general  development  she  had  the  appearance  of  a  child  of  twelve 
or  thirteen.  Her  mental  condition  was  backward  and  corre- 
sponded to  a  similar  age,  and  she  had  never  menstruated.  The 
mother  informed  me  that  the  girl  had  seemed  quite  all  right  in 
mind  and  body  until  about  four  years  previously,  but  since  then 
she  had  been  at  a  complete  standstill.  On  examination  the  thyroid 
gland  appeared  to  be  normal,  but  the  skin  was  sallow,  coarse,  dry, 
and  had  a  curious  boggy  feel,  the  hair  scanty,  the  mons  veneris 
uncovered,  the  lips  thick,  and  the  teeth  much  decayed.  There 
was  also  a  pronounced  flush  over  each  cheek.  She  was  extremely 
childish  for  her  age,  besides  being  unusually  torpid  in  thought  and 
movement.  In  view  of  these  symptoms,  I  decided  to  try  the  effect 
of  thyroid  treatment.  The  mother  noticed  improvement  after  the 
first  week,  and  after  three  months  menstruation  had  appeared 
and  a  great  change  was  evident  in  every  way.  She  was  under 
treatment  for  about  nine  months,  and  it  was  then  discontinued 
entirely.  The  mental  and  bodily  improvement  initiated  by  the 
thyroid  steadily  continued,  and  when  I  last  saw  her,  at  the  age 
of  twenty-one  years,  she  had  a  normal  appearance,  and  was  regu- 
larly employed  as  a  clerk  in  the  Post  Office.* 

NUTRITIONAL  AMENTIA. 
(AMENTIA  DUE  TO  MALNUTRITION.) 

In  addition  to  the  secretion  of  the  thyroid  gland,  it  is  possible 
that  there  may  be  other  internal  secretions  or  particular  chemical 
substances  which  are  essential  to  the  growth  of  the  nerve  cells, 
and  the  absence  of  which  gives  rise  to  imperfection  of  development 
and  mental  deficiency.  As  already  suggested,  it  may  be  that  some 
*  This  patient  remains  perfectly  well  five  years  later. 


292      Secondary  Amentia  and  its  Clinical  Varieties 

such  special  defect  is  responsible  for  the  curious  combination  of 
anomalies  present  in  Mongolism.  This,  however,  is  mere  conjecture. 
At  present  we  know  of  no  special  nutritive  agent  other  than 
the  thyroid  secretion,  and  the  cases  of  amentia  which  we  have 
now  briefly  to  consider  are  those  associated  with  general  mal- 
nutrition. 

A  state  of  general  malnutrition  is  by  no  means  uncommon  during 
intra-  or  early  extra-uterine  existence.  In  many  cases,  particu- 
larly those  happening  before  birth,  the  cause  is  obscure.  There  is 
no  hereditary  defect,  the  mother  has  appeared  quite  well  during 
gestation,  and  yet  for  some  reason  or  other  the  child  at  birth  is 
exceedingly  small,  feeble,  and  is  reared  with  the  greatest  difhculty. 
Many  of  these  children  are  the  first-bom,  others  are  the  last-bom, 
of  a  long  family,  and  it  may  be  that  in  the  one  the  female  generative 
organs  have  not  attained  their  full  physiological  capacity  for 
nourishing  the  ovum,  whilst  in  the  other  this  activity  is  on  the  wane. 
In  some  of  these  cases  there  is  a  very  definite  history  of  harass- 
ment, hardship,  ill-health,  or  even  serious  disease  whilst  the  mother 
was  carrying,  and  then  the  feeble  condition  of  the  child  is  more 
intelligible.  But  cases  occur  in  which  none  of  these  adverse 
factors  have  been  present,  and  in  which  no  cause  can  be  found  for 
the  child's  defective  nutrition. 

After  birth,  malnutrition  may  be  dependent  upon  disease,  in- 
sanitary surroundings,  or  mismanagement.  Although  there  has 
been  a  considerable  improvement  in  recent  years,  it  is  still  un- 
fortunately a  fact  that  the  conditions  under  which  thousands  of 
children  are  reared,  particularly  in  our  large  towns,  are  highly 
inimical  to  development.  This  is  sufficiently  attested  by  the  high 
infantile  mortality  rate.  For  instance,  in  his  Annual  Report  for 
the  year  1909,  the  Registrar-General  says:  "  There  is  every  reason 
for  congratulation  in  the  general  improvement  which  has  taken 
place  in  this  respect,  but  it  should  be  observed  that  while  there  are 
many  urban  and  mral  areas  in  England  and  Wales  where  the  loss 
of  infants  under  one  year  of  age  does  not  exceed  from  8  to  10  per 
cent,  of  the  total  births,  there  are,  on  the  other  hand,  many  manu- 
facturing and  mining  centres  where  the  wastage  of  child-hfe  is 
excessive,  the  loss  in  such  areas  in  the  first  year  of  life  amounting 
to  from  15  to  20  per  cent,  of  the  total  births."  Now,  there  can  be 
no  doubt  that  a  considerable  proportion  of  the  So  to  85  per  cent, 
of  survivals  are  exposed  to  the  same  adverse  surroundings,  and. 


Nutritional  Amentia  293 

although  they  escape  death,  their  nutrition  is  often  so  seriously 
impaired  as  to  impose  a  great  hindrance  to  their  physical  develop- 
ment. 

What  is  the  effect  of  such  malnutrition  upon  the  development 
of  the  brain  ?  However  good  may  be  the  inherent  potentiality, 
it  is  clear  that  development  cannot  take  place  to  the  full  in  the 
absence  of  a  food-supply  which  is  adequate  in  quality  and  quan- 
titv,  and  consequently  under  such  adverse  conditions  it  is  by  no 
means  uncommon  to  find  considerable  mental  retardation.  Such 
cases  may  simulate  amentia  so  closely  as  to  make  a  diagnosis 
impossible  at  the  time,  but  my  experience  is  that  it  is  extremely 
rare  for  mental  growth  to  be  permanently  arrested  by  these 
causes.  Some  embarrassment  is  felt  for  a  time,  but  when  the 
adverse  factors  are  removed,  the  child  rapidly  makes  up  the 
arrears.  The  condition,  in  fact,  is  one  of  mental  retardation 
Exceptionally,  however,  it  may  happen  for  the  malnutrition  to  be 
so  severe,  or  to  persist  so  long,  that  the  arrears  are  never  made 
up,  and  then  we  have  produced  some  degree  of  mental  deficiency 
of  the  secondary  form.  I  do  not  think  such  a  result  is  at  all  common, 
but  I  have  now  seen  a  number  of  cases  in  which  the  most  searching 
inquiry  failed  to  discover  any  other  cause,  and  I  am  disposed  to 
think  that  it  may  occur.  It  is  perhaps  not  unnecessary  to  point 
out  that  defective  nutrition  may  be  merely  the  determining  factor 
where  the  potentiality  for  development  is  already  defective,  and 
such  cases  form  one  variety  of  developmental  or  dela3'ed  primary 
amentia;  also  that  a  large  number  of  primary  aments  suffer  from 
malnutrition  as  a  consequence  of  their  defect.  In  the  present 
place  we  are,  of  course,  only  concerned  with  that  very  small 
proportion  of  cases  which  are  the  direct  result  of  malnutrition. 

It  is  obvious  that  the  longer  the  period  during  which  nutrition 
is  disordered,  the  greater  will  be  the  probability  of  permanent 
effect,  and  hence  it  follows  that  children  who  present  marked  signs 
of  this  at  birth  will  be  more  likely  .to  suffer  from  mental  defect 
than  will  those  who  are  normal  when  born.  It  is  in  agreement  with 
this  that  nearly  all  the  cases  I  have  seen  have  been  due  to  mal- 
nutrition during  intra-uterine  life.  Some  of  the  children  have  been 
born  prematurely,  others  at  full  term,  but  all  of  them  have  been 
very  much  below  the  normal  weight,  have  shown  marked  signs  of 
feebleness,  and  have  been  reared  with  the  greatest  difficulty.  One 
case  of  this  kind  which  I  saw  recently  was  the  only  child,  and  was 


294     Secondary  Amentia  and  its  Clinical  Varieties 

born  at  the  seventh  month.  The  mother  was  in  her  usual  health 
during  gestation,  but  she  is  a  delicate  woman.  At  birth  the  child 
was  extremely  small,  and  when  a  fortnight  old,  only  weighed 
2|  pounds.  As  a  result  of  unremitting  care  and  attention,  the 
parents  succeeded  in  rearing  her,  but  she  was  always  backward 
in  body  and  mind,  and  when  I  saw  her  at  the  age  of  three  and  a  half 
years,  she  was  no  bigger  than  an  average  baby  of  twelve  months. 
She  could  crawl,  but  was  quite  unable  to  stand  or  walk,  and  the 
dorsifiexion  of  the  great  toes  indicated  that  the  myehnation  of  the 
spinal  motor  tract  was  still  imperfect.  Movements  of  the  hands 
and  fingers  were  fair,  she  could  seize  anything,  and  could  pick  up 
a  sixpence  from  the  table.  She  was  quite  unable  to  speak,  and 
made  sounds  like  a  baby  during  its  first  year.  The  circumference 
of  the  skull  was  lyj  inches,  corresponding  to  that  of  a  normal  child 
between  the  ninth  and  twelfth  months,  and  there  was  a  considerable 
deficiency  in  the  frontal  and  parietal  regions;  but  there  were  none 
of  the  ordinary  stigmata  of  degeneracy.  The  child's  special  senses 
appeared  to  be  normal.  She  could  understand,  and  obey  simple 
commands,  was  fond  of  pictures,  and  pointed  to  such  common 
articles  as  a  key,  penny,  knife,  when  told  to  do  so.  Her  power 
of  attention  was  good,  and  she  would  amuse  herself  for  a  consider- 
able time  with  toys.  She  was  clean  in  her  habits,  and  could  feed 
herself;  in  fact,  her  mother  said  that  she  was  able  to  eat  an  egg 
with  a  spoon  as  neatly  as  a  grown-up  person.  Unfortunately,  the 
child  succumbed  shortly  afterwards  to  enteritis,  but  I  think  it  is 
highly  probable  that  had  she  lived  there  would  always  have  been 
some  mild  degree  of  mental  impairment.  A  somewhat  similar  case 
was  that  of  a  girl  brought  to  me  at  the  age  of  six  years,  who  in 
her  mental  and  physical  development  corresponded  to  a  normal 
child  of  about  three  years.  There  was  no  record  of  the  weight 
at  birth,  but  she  was  said  to  have  been  so  small  that  it  was  thought 
she  could  not  possibly  live.  Here,  also,  I  think  it  is  very  doubtful 
whether  mental  development  will  ever  be  complete.  I  have  seen 
several  similar  cases  which  have  arrived  at  maturity,  and  have 
then  presented  a  mild  degree  of  feeble-mindedness. 

With  regard  to  malnutrition  arising  after  birth,  the  effect  does  not 
seem  so  serious,  and,  as  I  have  already  remarked,  although  there 
may  be  some  mental  retardation,  this  is  usually  of  a  temporary  nature, 
and  is  recovered  from  as  the  physical  condition  improves.  Occa- 
sionally, however,  a  mild  degree  of  defect  remains,  but  it  is  always 


Isolation  Amentia  295 

mild,  and  I  have  never  known  or  heard  of  idiocy,  or  even  imbecihty, 
resulting  from  this  cause. 

One  of  the  commonest  disturbances  of  nutrition  occurring  in 
infancy  is  that  due  to  rickets,  and  a  "  rachitic  idiocy  "  has  been 
described.  I  have  never  seen  such  a  case.  Rickets  may,  of 
course,  complicate  primary  or  secondary  amentia,  and  there  can 
be  no  doubt  that  the  mental  development  of  the  rachitic  child  is 
often  delayed  and  abnormal;  but,  so  far  as  my  experience  goes, 
rickets  alone  has  never  produced  amentia.  On  the  contrary,  I 
know  several  adults  of  marked  intellectual  ability  who  show  clear 
evidence  of  having  suffered  from  severe  rickets  in  childhood. 


ISOLATION  AMENTIA. 

(AMENTIA  DUE  TO  ISOLATION  OR  SENSE  DEPRIVATION.) 

The  growing  brain  cells  not  only  require  to  be  supplied  with 
their  own  particular  food,  but  they  must  also  be  stimulated  by 
vibrations  transmitted  through  the  special  sense  pathways.  The 
effect  of  these  is  probably  similar  to  that  produced  by  rays  of 
light  upon  plant  development,  and  in  their  absence  cellular  growth 
is  as  imperfect  as  if  the  brain  had  been  starved.  This  is  well  shown 
by  the  marked  agenesis  of  the  occipital  cortex  which  occurs  as 
a  consequence  of  congenital  non-development  of  the  organs  of 
vision — a  fact  which  has  been  ably  utilized  by  J.  S.  Bolton  to 
accurately  map  out  the  visual  area.  But  not  only  are  sensations 
thus  necessary  for  growth :  they  are  also  the  materials  out  of  which 
thoughts  and  ideas  are  built,  and  the  sum  total  of  them  constitutes 
mind.  Should,  therefore,  a  single  sensory  avenue  be  closed,  as  in 
blindness  or  deafness,  the  mind  must  for  ever  remain  the  poorer 
by  the  impressions  which  would  have  entered  through  this  channel, 
and  if  two  or  more  senses  are  defective,  the  mind  may  be  so  im- 
poverished as  to  bring  about  a  condition  of  true  amentia. 

As  we  have  already  seen,  such  sensory  defects  are  occasionally 
present  in  primary  amentia,  and  they  are  then  complications 
which  usually  impose  an  insuperable  obstacle  to  successful  train- 
ing. In  secondary  amentia,  however,  which  we  are  now  consider- 
ing, there  is  no  intrinsic  incapacity  of  the  cortical  neurones,  and 
if  other  sensory  channels  can  be  so  utilized  as  to  compensate  in 
some  degree  for  those  diseased,  the  mental  capacity  may  be  but 
little    impaired.     Suitable    training    may    therefore    prevent    the 


296     Secondary  Amentia  and  its  Clinical  Varieties 

development  of  secondary  amentia  from  these  causes.  That  this 
is  so  is  fully  shown  by  the  excellent  results  achieved  in  training 
establishments  for  the  blind  and  deaf,  as  well  as  by  some  classical 
examples  in  which  disease  of  several  sensory  channels  had  existed. 

The  common  cause  of  the  sensory  deprivation  in  these  cases  is 
inflammation  resulting  from  one  or  other  of  the  infectious  fevers; 
the  lesion  is  usually  at  the  periphery,  and  the  organs  most  fre- 
quently affected  are  those  of  sight  and  hearing.  Amentia  can 
only  result  when  such  occurs  during  early  childhood  (whilst  cerebral 
development  is  immature),  and  where  special  educational  training 
has  been  withheld  or  has  failed.  In  the  absence  of  a  neuropathic 
inheritance  I  believe  failure  to  be  exceedingly  rare,  and  the  cases 
of  this  form  of  amentia  which  are  met  with  are  nearly  always  in 
persons  whose  early  education  has  been  neglected.  They  are,  in 
fact,  as  much  sufferers  from  a  deprivation  of  special  education  as 
of  special  sense.  I  have  met  several  such  cases  in  remote  country 
districts.  The  child,  deprived  of  sight  or  hearing  in  early  life, 
is  thereby  excluded  from  the  village  school.  The  local  authority 
provides  no  special  form  of  education,  and  does  not  further  concern 
itself  with  him.  There  may  be  institutions  for  the  blind  and  deaf 
but  ten  miles  away,  but  it  is  no  particular  person's  business  to 
secure  him  admission,  and  he  gradually  grows  up  without  any 
training.  He  soon  passes  the  age  at  which  such  would  be  of  avail,, 
and  becomes  an  incurable  ament.  Although  such  a  state  of  affairs 
still  exists,  it  is  less  common  than  in  years  gone  by.  The  necessity 
for,  and  great  benefit  to  be  derived  from,  training  is  now  much 
more  generally  recognized,  and  in  consequence  cases  of  amentia 
due  to  sense  deprivation  are  not  nearly  so  prevalent  as  formerly. 
At  the  present  time  they  comprise  only  a  fraction  of  all  cases  of 
amentia,  although  the  total,  number  in  existence  is  still  consider- 
able. 

These  patients  are  usually  well  grown  and  free  from  any  stig- 
mata of  degeneracy.  In  the  majority  of  instances  the  mental 
defect  is  mild,  but  it  is  not  uncommon  for  it  to  be  accompanied 
by  hallucinations  and  delusions,  and  sometimes  the  behaviour  is 
so  erratic  and  untrustworthy  as  to  necessitate  committal  to  an 
asylum  for  the  insane. 


Isolation  Amentia  297 

Illustrative  Cases. 

The  two  following  are  good  examples  of  this  form  of  amentia 
as  commonly  met  with : 

Mild  Amentia  consequent  itpon  Early  Deafness. — W.  S.,  male, 
fifteen  years  of  age.  No  morbid  heredity.  Was  either  born  deaf 
or  became  so  shortly  after  birth,  and  has  never  spoken.  He  was 
refused  admission  to  the  village  school,  and  has  received  no  educa- 
tion. He  is  well  grown  for  his  age,  and  has  a  pleasing  expression. 
He  can  understand  many  signs,  and  can  express  many  of  his 
wants  in  the  same  way.  Beyond  helping  his  mother  in  the  house 
at  times,  he  is  quite  unemployed.  He  is  by  no  means  lacking  in 
the  faculties  of  imitation  and  imagination,  and  is  fond  of  drawing 
on  a  slate  or  scraps  of  paper.  It  is  quite  evident,  however,  that 
his  ideas  are  extremely  crude  and  childish.  In  addition  to  his 
intellectual  defect,  he  has  little  power  of  control,  and  is  becoming 
more  and  more  subject  to  outbreaks  of  passion  and  waywardness. 
On  several  occasions  he  has  wandered  away  from  home.  His 
mother  states  that  he  is  affectionate,  but  "  cannot  bear  to  be 
crossed,"  I  am  of  opinion  that  in  this  case  suitable  training  in  a 
school  for  the  deaf  would  have  prevented  the  mild  amentia  now 
present,  and  would  have  resulted  in  the  patient  becoming  a  useful 
member  of  society.  Even  at  this  age  I  strongly  urged  the  desira- 
bility of  such  training,  as  without  it  there  is  no  doubt  that  he  will 
gradually  become  more  intractable,  and  will  finally  drift  into  an 
insane  asylvmi. 

The  Earlswood  case  also  is  probably  one  of  amentia  due  to 
deafness,  but  as  this  patient  has  developed  a  most  extraordinary 
degree  of  mechanical  skill,  I  have  thought  it  better  to  describe  him 
under  the  chapter  on  Idiots  Savants. 

Mild  Amentia  consequent  upon  Congenital  Blindness. — E.  W.  C, 
male.  Born  blind.  No  education.  Admitted  into  imbecile  in- 
stitution at  the  age  of  fifteen,  but  found  to  be  intractable  and 
violent,  and  transferred  to  lunatic  asylum.  He  is  now  twenty-nine 
years  of  age,  and  is  a  tall,  well-developed,  and  well-nourished  man 
of  pleasing  expression.  Cranial  circumference,  22|  inches.  No 
stigmata  of  degeneracy.  He  is  quite  blind,  the  eyes  being  repre- 
sented by  rudimentary  bulbs  of  white,  opaque,  sclerotic  tissue 
wdthout  an}'  indication  of  cornea  or  iris.  His  memory  is  good; 
he  has  a  tolerably  good  knowledge  of  places  and  events,  can  under- 


298      Secondary  Amentia  and  its   Clinical   Varieties 

stand  all  that  is  said  to  him,  and  can  give  a  fair  account  of  himself. 
He  possesses  imagination,  but  his  ideas  are  simple  and  childish, 
and  his -power  of  reasoning  is  decidedly  defective.  He  cannot  read, 
write,  sum,  or  do  any  kind  of  work,  and  he  spends  the  day  rocking 
himself  to  and  fro  in  a  chair  and  muttering  to  himself.  After 
answering  a  question,  he  rambles  on  to  himself  in  an  incoherent 
way  about  analogies  and  philosophy.  When  asked  what  a  philoso- 
pher is,  he  says :  "  A  man  who  tries  to  make  everybody  else  better." 
He  then  immediately  goes  on  to  talk  about  Ally  Sloper,  which,  he 
says,  has  been  read  to  him.  He  has  aural  hallucinations  and 
delusions,  and  is  very  emotional  and  untrustworthy.  In  spite  of 
his  beatific  appearance,  he  is  liable  to  frequent  outbreaks  of  sudden 
violence,  and  has  repeatedly  attacked  the  other  patients.  He  is 
also  a  confirmed  masturbator.     (See  Plate  XXH.,  Fig.  53.) 

The  following  well-known  cases  may  be  briefly  referred  to  in 
this  pla.ce,  as  showing  the  really  remarkable  results  which  may 
attend  the  systematic  education  of  patients  suffering  from  severe 
sense  deprivation. 

Laura  Dewey  Bridgman* — An  attack  of  scarlet  fever  at  the  age 
of  two  years  caused  suppuration  of  both  eyes  and  both  ears;  taste 
and  smell  were  also  impaired.  She  was  quite  deaf,  and  sight  was 
entirely  abolished  in  the  left  eye ;  but  she  retained  a  slight  percep- 
tion of  light  in  the  right  eye  up  to  the  eighth  year,  after  which  she 
became  completely  blind.  She  was  admitted  to  the  Perkins  In- 
stitution for  the  BHnd  at  Massachusetts  at  the  age  of  seven  years 
ten  months,  and  received  systematic  education  under  Dr.  Howe 
until  she  was  twenty.  Owing  to  the  unremitting  care  and  patience 
of  Dr.  Howe  in  training  her  cutaneous  sensation  (the  only  sense 
unimpaired),  she  became  able  to  read  and  write  in  the  deaf  and 
dumb  language,  to  express  many  of  her  feelings,  to  sew,  knit,  and 
perform  certain  household  duties,  and,  in  short,  to  live  to  a  great 
extent  the  life  of  an  ordinary  person.  She  remained  in  the  Perkins 
Institution  until  her  death,  at  the  age  of  sixty  years.  The  general 
conclusion  arrived  at  regarding  her  by  Mr.  Sangford  was  that  "  she 

*  See  the  "  Life  of  Laura  Bridgman,"  by  M.  S.  Lamson,  Boston,  1878; 
also  an  account  by  Dr.  Howe  in  the  Forty-Third  Annual  Report  of  the 
Perkins  Institution  and  Massachusetts  Asylum  for  the  Blind.  A  very  good 
abstract  of  this  is  given  by  Dr.  Ireland  in  his  "  Mental  Affections  of  Children." 

The  brain  was  very  carefully  examined  by  Dr.  H.  H.  Donaldson,  and 
described  by  him  in  the  American  Journal  of  Psychology,  September,  1890, 
and  December,  1891. 


Plate  XXII. 


To  face  page  298.] 


Isolation   Amentia  299 

was  eccentric,  not  defective;  she  lacked  certain  data  of  thought, 
but  not  in  a  very  marked  way  the  power  to  use  what  data  she  had." 
The  post-mortem  examination  showed  that  the  auditory  nerves, 
the  optic  nerves  and  tracts,  and  the  olfactory  bulbs,  were  very  small. 
The  grey  matter  of  the  cortex  generally  was  thinner  than  usual, 
especially  in  the  occipital,  cuneus,  and  temporal  lobes.  In  these 
situations  there  was  also  a  deficiency  in  the  number  of  nerve  cells. 
There  was  a  considerable  non-development  of  the  inferior  frontal 
and  temporo-sphenoidal  convolutions  covering  the  island  of  Reil, 
particularly  marked  on  the  left  side.  The  cranial  circumference 
was  20-8  inches. 

In  two  other  pupils  of  the  Perkins  Institution — namely,  Oliver 
Caswell  and  Helen  Keller — the  results  were  almost  equally  re- 
markable. Miss  Helen  Keller  lost  sight  and  hearing  at  the  age 
of  nineteen  months.  She  received  unremitting  care,  and  soon 
mastered  the  deaf  and  dumb  language.  By  means  of  the  Braille 
system  she  subsequently  acquired  French,  German,  Greek,  and 
Latin,  and  then  developed  the  power  of  oral  speech.  She  passed 
the  Harvard  preliminary  examination  with  honours  at  the  age 
of  nineteen  years,  and  had  a  distinguished  college  career,  after- 
wards writing  several  books,  and  evincing  high  intellectual  capacity. 
Meystre,  of  Lausanne  (Switzerland),  was  born  deaf  and  dumb,  and 
he  lost  his  sight  by  an  accident  at  the  age  of  five  years.  By  un- 
remitting attention  he  was  taught  to  articulate,  and  at  the  age 
of  eighteen  he  was  described  as  "  a  lively,  intelligent,  and  good- 
humoured  fellow,  an  excellent  carpenter,  a  first-rate  turner,  and 
runs  about  the  building  with  a  certainty  and  confidence  which 
none  of  the  merely  blind  pupils  acquire.  He  has  a  great  many 
ideas,  and  an  instinctive  dread  of  death." 

Agnes  Halonen*  was  born  in  Finland  in  1886.  At  the  age  of 
eighteen  months  she  became  blind  from  scarlet  fever,  and  a  year 
afterwards  became  deaf.  She  very  soon  ceased  to  speak,  and 
expressed  her  wants  by  means  of  a  few  simple  signs,  such  as  putting 
her  hand  to  her  mouth  when  she  wanted  food.  She  could  recognize 
members  of  her  family  by  touch.  At  the  age  of  eight  she  was  sent 
to  the  Blind  School  at  Helsingfors.  Here  she  was  taught  to  sew 
and  knit,  as  well  as  the  finger  alphabet.  At  the  age  of  seventeen 
she  could  read  books  in  Braille  and  Moon's  characters,  and  she 

*  "  The  Blind  Deaf-Mute,  Agnes  Halonen,"  by  Aug.  Helin,  Stockholm. 
Abstract  in  Journal  of  Menial  Science,  April,  1904,  p.  336. 


300     Secondary   Amentia  and  its  Clinical  Varieties 

could  also  write.  She  had  some  knowledge  of  geography,  which 
had  been  taught  her  by  means  of  raised  maps.  She  knew  many  of 
the  capitals,  mountains,  and  rivers  in  Europe  and  Asia,  and  she 
had  a  knowledge  of  the  habits  of  plants  and  animals.  She  was 
able  to  sew,  spin,  crochet,  plait,  and  make  brushes,  and  generally 
was  very  intelligent. 

Kaspar  Hauser.— No  account  of  this  subject  would  be  complete 
without  a  brief  reference  to  this  celebrated  and  mysterious  case. 
It  differs  from  the  foregoing  in  that  there  was  no  disease  of  the 
sensory  pathways,  but  the  environment  of  the  child  for  many 
3^ears  was  such  that  they  could  not  be  exercised.  It  may  fittingly 
be  described  as  a  case  of  mental  arrest  due  to  isolation. 

On  May  26,  1828,  a  youth,  apparently  about  sixteen  or  seven- 
teen years  of  age,  was  found  near  one  of  the  gates  of  Nuremberg. 
He  was  unable  to  give  any  account  of  himself,  and  inquiries  failed 
to  discover  how  or  whence  he  came  or  who  he  was.  He  was  4  feet 
9  inches  in  height,  very  pale,  with  short,  delicate  beard  on  his 
chin  and  upper  lip.  His  feet  were  tender  and  blistered,  and  showed 
no  signs  of  having  been  confined  in  shoes.  He  scarcely  knew  how 
to  use  his  fingers  or  hands,  and  his  attempts  at  walking  resembled 
the  first  efforts  of  a  child.  He  could  not  understand  what  was  said 
to  him,  and  replied  to  all  questions  by  a  single  phrase:  "  I  will  be 
a  trooper,  as  my  father  was."  His  countenance  was  expressive 
of  gross  stupidity.  He  appeared  to  be  hungry  and  thirsty,  but 
refused  everything  offered  to  him  except  bread  and  water.  He 
held  in  his  hand  a  letter  stating  that  the  bearer  had  been  left  with 
the  writer,  who  was  a  poor  labourer  with  ten  children,  in  October, 
1812,  and  who,  not  knowing  his  parents,  had  brought  him  up  in 
his  house,  without  allowing  him  to  stir  out  of  it.  This  was  regarded 
as  being  intended  to  deceive.  Upon  a  pen  being  placed  in  his  hand, 
the  youth  wrote  the  words  "  Kaspar  Hauser." 

After  an  official  inquiry — which,  however,  revealed  nothing — 
he  was  adopted  by  the  town  of  Nuremberg,  and  Professor  Daumer 
undertook  his  education.  He  was  found  to  be  extremely  child- 
like, and  to  have  no  knowledge  of  the  most  simple  facts  of  every- 
day life.  But  he  had  a  remarkable  faculty  of  smell  and  for  seeing 
things  in  the  dark,  and  under  the  instraction  of  Daumer  his  mind 
expanded  in  a  wonderful  manner.  In  fact,  probably  as  a  conse- 
quence of  its  sudden  awakening  into  activity,  he  became  ill,  and 
his  education  had  to  be  discontinued  for  a  time. 


Isolation  Amentia  301 

He  was  taught  the  use  of  language,  and  after  a  time  was  able 
to  record  his  recollections.  He  said  that  he  had  always  lived  in  a 
small,  dark  cell,  continually  seated  on  the  ground.  He  had  had 
no  covering,  except  a  shirt  and  trousers,  and  had  never  seen  the 
sky.  When  he  awoke  from  sleep  he  was  accustomed  to  find  near 
him  some  bread  and  a  pitcher  of  water,  but  he  never  saw  the  face 
of  the  person  who  brought  them,  and  he  had  no  knowledge  that 
there  were  any  other  living  creatures  besides  himself  and  the  man 
who  brought  him  food.  This  man  eventually  taught  him  to  write 
his  own  name,  and  finally  brought  him  to  the  Nuremberg  gate. 

For  a  time  mental  development  took  place  with  great  rapidity, 
but  the  prolonged  isolation  had  wrought  an  effect  upon  the  brain 
cells  from  which  they  could  not  completely  recover,  and  after  a 
time  their  potentiaUty  became  exhausted  and  no  further  progress 
was  made.  He  was  taken  under  the  protection  of  Lord  Stanhope, 
and  he  was  subsequently  employed  in  the  Court  of  Appeal,  but 
he  showed  little  real  capacity  for  work.  On  October  17,  1829,  he 
was  found  bleeding  from  a  slight  wound  which  he  said  had  been 
inflicted  by  a  stranger.  On  December  14,  1S33,  at  Anspach,  he 
met  a  stranger  by  appointment,  on  the  promise  that  the  mystery 
of  his  birth  would  be  revealed.  During  the  interview  he  was 
mortally  stabbed,  and  he  died  three  days  afterwards. 

A  post-mortem  examination  showed  a  somewhat  thickened  skull 
and  rather  small  brain,  which  did  not  completely  overlap  the  cere- 
bellum. The  convolutions  of  the  brain  were  also  simpler  than 
normal. 

The  mystery  of  Kaspar  Hauser's  birth  and  death  attracted 
widespread  interest,  and  has  never  been  solved.  It  was  contended 
by  Earl  Stanhope  and  the  Duchess  of  Cleveland  that  he  was  an 
impostor,  but  this  view  was  strongly  combated  by  both  Professor 
Daimier  and  the  eminent  Bavarian  jurist,  Von  Feuerbach.  The 
latter  considered  that  Hauser  was  heir  to  a  princely  German  house, 
put  out  of  the  way  to  favour  another  succession.  A  careful  ex- 
amination of  the  facts  regarding  his  condition  when  first  found,  his 
subsequent  limited  progress,  his  untimely  and  mysterious  death, 
and  the  state  of  his  brain,  seem  to  show  that  his  account  was  a 
truthful  one,  and  that  he  exemplifies  in  a  unique  manner  the  effects 
of  a  prolonged  isolation  upon  the  cells  of  the  brain. 


CHAPTER  XIV 
IDIOTS    SAVANTS 

We  have  seen  that  amentia  is  often  characterized  by  an  irregular 
as  well  as  a  defective  mental  development,  and  in  a  small  number 
of  patients  this  is  so  marked  as  to  result  in  special  aptitudes 
which  are  quite  phenomenal,  not  merely  in  comparison  with  aments, 
but  often  with  the  acquirements  of  ordinary  persons.  These  persons 
are  conveniently  described  as  "idiots  savants."  The  condition  is 
exceptional  and  relatively  uncommon;  on  the  other  hand,  it  is  not 
so  rare  but  that  a  considerable  number  of  cases  have  been  recorded. 

Presumably  the  special  aptitude  is  related  to  an  increased  de- 
velopment of  certain  cerebral  neurones,  but  as  to  how  and  why 
this  is  brought  about  we  can  only  conjecture.  In  many  of  the 
cases  I  have  seen  there  has  been  a  clearly  marked  predilection 
(which,  however,  has  rarely  been  marked  in  the  ancestors),  and  I 
can  only  assume  that  this  is  the  result  either  of  some  primary  develop- 
mental anomaly  or  of  some  fortuitous  circumstance  of  early  life 
which  has  aroused  the  child's  interest  in  a  particular  direction,  and 
thence  led  to  the  concentration  of  all  his  mental  activities  upon  the 
one  object.  The  talent,  whatever  it  is,  and  however  originating, 
certainly  owes  much  of  its  development  to  constant  exercise. 

It  is  to  be  noticed  that  although  these  persons  are  spoken  of  as 
"  idiots,"  they  are  rarely  of  the  lowest  grade  of  mental  defect. 
Most  of  them  would  more  properly  be  classed  as  imbeciles  or  merely 
feeble-minded.  It  is  remarkable,  however,  that  they  almost  in- 
variably belong  to  the  male  sex,  female  idiots  savants  being  very  rare. 

Peterson  is  of  opinion  that  the  talents  of  these  persons  lie  chiefly 
in  the  direction  of  imitation,  and  that  they  have  no  capacity  for 
originating.  He  also  thinks  that  they  are  frequently  lost  before 
adult  life.  These  statements  are  undoubtedly  true  of  many  cases, 
but  they  are  by  no  means  invariably  so.     I  doubt  whether  the  latter 

302 


Idiots  Savants  303 

one  is  even  the  rule,  and  several  illustrations  to  the  contrary  will 
be  cited  in  the  following  pages. 

The  nature  of  these  phenomenal  acquirements  varies  consider- 
ably. In  some  persons  the  talent  consists  of  an  extraordinary 
development  of  one  of  the  special  senses.  Thus,  Jules  Voisin 
describes  the  case  of  an  imbecile  with  a  wonderful  delicacy  of  smell. 
She  never  ate  or  drank  anything  without  smelling  it,  and  if  given 
coffee  (for  which  she  had  a  great  fondness)  in  a  glass  which  had 
contained  wine,  she  would  at  once  detect  it  and  refuse  to  drink. 
Imbeciles  have  been  described  who  were  able  by  the  sense  of  smell 
to  pick  out  their  own  and  their  companion's  clothes,  and  Seguin 
noticed  many  idiots  even,  in  whom  this  faculty  was  developed  to  an 
extraordinary  degree. 

In  other  cases  there  is  an  increased  development  of  the  visual 
sense.  Several  of  the  drawing  and  mechanical  geniuses  have  a 
wonderful  capacity  for  detecting  slight  differences  of  form  and  size, 
whilst  the  following  case,  mentioned  to  me  by  Dr.  R.  Langdon 
Down,  is  an  excellent  example  of  this  class.  It  is  that  of  a  boy,  a 
patient  at  Normansfield,  whose  hobby  was  the  collection  of  small 
bright  articles  of  any  description,  and  this  interest  had  so  cultivated 
his  quickness  and  sharpness  of  sight  that  nothing  in  the  shape  of  a 
pin,  a  minute  fragment  of  broken  glass,  or  any  shining  particle, 
which  was  invisible  to  the  ordinary  person,  ever  escaped  him. 
Other  patients  have  a  phenomenal  sense  of  hearing — as,  for  example, 
the  wild  boy  of  Aveyron  described  by  Itard,  as  well  as  some  who 
will  presently  be  mentioned  on  account  of  their  speech  and  memory. 
Finally,  there  are  some  cases  in  which  the  hyper-development  con- 
cerns the  tactile  sense.  Dr.  R.  Langdon  Down  tells  me  that  there 
used  to  be  a  boy  at  Normansfield  whose  sense  of  touch  was  so 
delicate  and  fingers  so  deft  that  he  could  take  a  page  of  the  Graphic 
and  gradually  split  it  into  two  perfect  sheets,  as  one  would  peel  a 
postage-stamp  off  an  enevlope. 

In  another  group  of  cases  it  is  chiefly  in  the  motor  functions  that 
these  extraordinary  talents  lie.  Sometimes  there  is  an  almost 
incredible  capacity  for  the  performance  of  mechanical  work  requiring 
the  greatest  cunning  and  dexterity,  and  as  an  example  of  this  the 
Earlswood  case,  which  will  presently  be  described,  is  probably 
unique.  In  other  persons  the  gift  takes  the  form  of  drawing,  and 
many  of  the  walls  of  Earlswood  Asylum  are  at  the  present  time 
adorned  by  beautifully  executed  crayon  drawings  (copies  of  well- 


304  Idiots  Savants 

known  pictures)  which  were  done  by  the  mentally  deficient  brother 
of  the  patient  just  referred  to.  Occasionally  the  talent  for  drawing 
passes  beyond  mere  picture-copying,  and  shows  the  presence  of  a 
real  artistic  capacity  of  no  mean  order.  This  was  the  case  with  the 
celebrated  Gottfried  Mind,*  who  had  such  a  marvellous  faculty  for 
drawing  pictures  of  cats  that  he  was  known  as  "  The  Cats'  Raphael." 
Gottfried  Mind  was  a  cretin  imbecile  who  was  born  at  Berne  in  1768, 
and  died  in  the  same  city  at  the  age  of  forty-six  years.  At  an  early 
age  he  showed  considerable  talent  for  drawing,  and  as  it  was  obvious 
that  he  would  never  be  able  to  earn  his  living  in  any  ordinary 
occupation,  his  father's  employer  interested  himself  in  providing 
young  Gottfried  with  some  training.  He  could  neither  read  nor 
write,  he  had  no  idea  of  the  value  of  money,  his  hands  were  remark- 
able for  their  large  size  and  roughness,  and  his  general  appearance 
was  so  obviously  indicative  of  mental  defect  that  his  walks  through 
the  city  were  usually  to  the  accompaniment  of  a  crowd  of  jeering 
children.  In  spite  of  all  this  his  drawings  and  water-colour  sketches 
of  not  only  cats,  but  of  deer,  rabbits,  bears,  and  groups  of  children, 
were  so  marvellously  lifelike  and  so  skilfully  executed  that  he 
acquired  a  European  fame.  One  of  his  pictures,  indeed,  of  a  cat 
and  kittens  was  purchased  by  King  George  IV. 

Under  the  heading  of  motor  we  may  also  describe  those  cases 
possessing,  if  not  the  gift  of  tongues,  at  all  events  an  extraordinary 
capacity  for  reproducing  spoken  words.  Dr.  Martin  W.  Barry 
describes  an  epileptic  idiot,  aged  twenty-two  j'ears,  who,  in  spite 
of  the  most  careful  teaching,  could  learn  neither  to  read  nor  to 
write,  although  he  was  able  to  perform  small  domestic  duties. 
Spontaneously  he  hardly  spoke  at  all,  and  then  only  short  dis- 
connected words  or  the  simplest  sentences;  but  he  had  an  extra- 
ordinary capacity  for  repeating  fluently  and  with  proper  intonation 
everything  said  to  him  whether  in  his  mother-tongue  or  in  such 
languages  as  Greek,  Japanese,  Danish,  Spanish,  etc.  Probably 
those  cases  in  which  an  imbecile  will  reel  off  cantos  of  poetry  ver- 
batim also  belong  to  this  category. 

In  a  considerable  proportion  of  these  idiots  savants  the  gift  is 
one  of  memory  in  some  form  or  other,  and  of  this  many  interesting 

*  See  an  interesting  account  of  Gottfried  Mind,  with  many  illustrations  of 
his  work,  in  the  The  Animal  World,  January,  1909,  by  E.  G.  Fairholme. 

t  M.  W.  Barr,  "  Some  Notes  on  Echolalia,"  Journal  of  Nervous  and  Mental 
Disease,  Januar}',  1898. 


Idiots  Savants  305 

and  remarkable  examples  have  been  described.  At  the  present 
time  there  are  two  such  in  Earlswood  Asylrmi.  One  of  them  is  a 
man,  sixty-five  years  of  age,  suffering  from  high-grade  amentia, 
whose  penchant  is  biographical  history.  It  is  only  necessary  to 
mention  to  him  the  name  of  any  prominent  personage  in  early  or 
ancient  history,  and  out  there  flows  in  a  steady,  unhesitating  stream 
a  full  account  of  his  birth,  life,  and  death.  His  knowledge  has  been 
acquired  by  poring  over  biographical  details  in  such  books  as  were 
available,  and  is,  of  course,  simply  a  matter  of  memory.  It  is  not, 
however,  merely  repetitive,  for  he  stands  cross-questioning  in  a 
manner  which  shows  that  he  has  some  knowledge,  although  not  full 
understanding,  of  the  occurrences  he  is  talking  about.  Dr.  Calde- 
cott  teUs  me  that  until  the  last  few  years  there  has  been  no  decline 
in  this  man's  capacity;  latterly,  however,  he  has  begun  to  show 
signs  of  mental  and  bodily  old  age.  The  other  case  is  a  somewhat 
younger  man,  aged  fifty-six  years,  whose  memory  also  relates  to 
dates  and  occurrences,  but  only  such  as  have  come  under  his  own 
notice.  He  is  a  most  valuable  referee  on  matters  connected  with 
the  previous  life  of  the  institution,  and  can  repeat  the  year,  month, 
and  day  of  coming  and  going,  of  all  the  medical  of&cers  during  his 
period  of  residence. 

Dr.  R.  Langdon  Down  showed  me  a  similar  case  at  Normans- 
field,  the  patient  being  a  high-grade  imbecile  thirty-eight  years  of 
age.  In  this  case  the  phenomenal  memory  chiefly  relates  to 
number,  but  the  patient  has  also  a  pronounced  sense  of  locality. 
His  speciality  is  the  calendar,  and  if  given  any  date  during  the  last 
five  years,  he  will  state  the  day  of  the  week  correctly  without  any 
hesitation.  But  he  seems  almost  equally  at  home  with  the  hymn- 
book,  and  will  promptly  give  the  number  of  any  hymn  of  which  he  is 
given  the  first  line,  or  vice  versa.  His  home  is  near  Maida  Vale,  and 
on  being  asked  what  streets  he  would  have  to  pass  through  in 
going  home  from  Waterloo  terminus,  he  named  each  one  without 
the  slightest  hesitation.  This  patient  can  also  give  the  product 
of  any  two  numbers  under  twenty  with  the  rapidity  of  a  reflex 
movement. 

A  similar  case  was  shown  by  Dr.  Witzmann  at  a  meeting  of  the 
Society  for  Psychiatry  and  Neurology  in  Vienna.*  The  patient,  an 
inmate  of  an  idiot  asylum,  aged  twenty  years,  possessed  an  extra- 
ordinary memory  for  certain  of  the  data  recorded  in  calendars. 

*   Reported  in  the  Lancet,  June  5,  1909,  p.  1641. 

20 


306  Idiots  Savants 

He  could  tell  with  the  utmost  readiness  what  day  of  the  week  it  had 
been,  or  would  be,  on  any  given  date  of  the  month  in  any  year  during 
the  long  period  from  the  year  1000  of  the  Christian  era  until  the 
year  2000.  He  also  knew  the  patron  saint  of  each  daj^  of  the 
month.  For  instance,  such  test  questions  as  the  following  were  put 
to  him,  and  answered  correctly  instantly.  Question  :  What  was  the 
day  of  the  week  on  October  3,  1907  ?  Answer  :  Thursday.  Ques- 
tion :  What  was  the  day  of  the  week  on  June  14,  1808  ?  Answer : 
1808  was  a  leap  year;  June  14  was  a  Tuesday.  The  patient  could 
read  and  write  only  tolerably  well,  was  backward  in  arithmetic, 
and  had  no  aptitude  whatever  for  manual  work.  It  seem.ed  prob- 
able that  he  had  actually  learned  by  heart  the  date  of  Easter 
for  each  year  from  1000  to  2000,  and  that  his  memory  of  this, 
together  with  some  kind  of  simple  code  of  his  own  devising,  enabled 
him  to  give  the  correct  answers  almost  immediately. 

Dr.  Forbes  Winslow*  mentions  the  case  of  a  man  who  could 
remember  "  the  day  when  every  person  had  been  buried  in  the 
parish  for  thirty-five  years,  and  could  repeat  with  unvarying 
accuracy  the  name  and  age  of  the  deceased,  and  the  mourners  at  the 
funeral.  But  he  was  a  complete  fool.  Out  of  the  line  of  burials  he 
had  not  one  idea,  could  not  give  an  intelligible  reply  to  a  single 
question,  nor  be  trusted  even  to  feed  himself." 

Other  cases  show  the  existence  of  this  phenomenal  memory  in 
its  simplest  automatic  form.  Thus,  there  are  many  idiots  wha 
cannot  speak  a  single  word,  and  yet  can  himi  a  tune,  which  they 
have  only  heard  once,  with  perfect  accuracy.  Other  aments  will 
reel  off  poetry  almost  ad  infinitum,  yet  without  any  understandings 
of  the  sense  of  what  they  are  saying,  or  even  of  the  meaning  of  the- 
words.  Dr.  Langdon  Down  has  described  the  case  of  a  bo}^  who, 
having  read  a  book,  would  correctly  recite  whole  pages  word  for 
word.  Dr.  Maudsley  mentions  the  case  of  an  imbecile  who  could 
similarly  repeat  verbatim  a  newspaper  he  had  just  read,  as  well  as 
another  more  remarkable  patient  who  could  repeat  backwards  what 
he  had  just  read. 

Most  aments  are  fond  of  music,  and  some  particularly  so,  but  in. 
a  few  instances  this  propensit}^  has  an  extraordinary  development. 
One  of  the  most  striking  examples  of  this  is  furnished  by  Dr.  Trelat, 
and  this  case  is  also  interesting  in  being  a  female.     Dr.  Trelatf  says- 

*  Quoted  by  Ireland. 

7  Trelat,  "  La  Folie  Lucide,"  etc.,  Paris,  1861.     Quoted  by  Ireland. 


The  Genius  of  Earlswood  Asylum  307 

that  "  they  had  in  the  Salpetriere  an  imbecile  born  bhnd,  affected 
with  rickets,  and  crippled,  who  had  great  musical  talents.  Her 
voice  was  very  correct,  and  whenever  she  had  sung  or  heard  some 
piece  she  knew  perfectly  well  the  words  and  the  music.  As  long  as 
she  lived  they  came  to  her  to  correct  the  mistakes  in  singing  of  her 
companions;  they  asked  her  to  repeat  a  passage  which  had  gone 
wrong,  which  she  always  did  admirably.  One  day,  Geraldy  Liszt 
and  Meyerbeer  came  to  the  humble  singing-class  of  our  asylum  to 
bring  her  their  encouraging  consolations."  Dr.  Seguin  and  Dr. 
Barr*  also  record  cases  in  which  a  pronounced  musical  capacity  was 
present. 

Lastly,  in  marked  contradiction  to  the  general  failing  of  aments 
in  this  respect,  a  few  of  these  persons  have  an  extraordinary  capacity 
for  arithmetic  and  calculations.  One  case  described  by  Dr. 
J.  Langdon  Down  is  that  of  an  inmate  of  Earlswood  Asylum,  an 
imbecile  boy  of  twelve  years,  who  could  multiply  three  figures  by 
three  other  figures  with  lightning  rapidity.  Dr.  Howe  has  also 
recorded  the  case  of  a  low-grade  ament  who,  if  told  the  age  of 
anyone,  would  in  a  very  short  time  calculate  the  number  of  minutes 
he  had  lived.  Dr.  Wizelf  also  records  the  case  of  an  imbecile 
(apparently  suffering  from  secondary  amentia)  who  had  a  most 
remarkable  faculty  for  arithmetic,  particularly  multiplication  and 
division.  For  instance,  she  divided  (mentally)  576,  560,  and  336 
by  16  with  astonishing  quickness;  she  multiplied  such  numbers  as 
23  X  23,  45  X  18,  78  X  78,  almost  immediately  and  by  a  peculiar 
method  of  her  own.  And  yet  at  addition  and  subtraction  she  was 
remarkably  poor,  and  said  that  57  +  63=141,  48  +  53=163.  At 
the  present  time  there  is  a  mentally  defective  boy,  aged  twelve 
years,  in  the  Littleton  Home  who  possesses  the  same  gift,  although 
markedly  lacking  in  other  scholastic  acquirements. 

We  may  conclude  this  chapter  on  idiots  savants  with  an  account  of 
the  following  extremely  interesting  case : 


The  Genius  of  Earlswood  Asylum. 

Since  the  year  1850  there  has  been  resident  in  Earlswood  Asylum 
a  patient  who  has  justly  earned  this  title,  and  whose  skill  in  drawing, 
invention,  and  mechanical  dexterity  is  certainly  unequalled  by  an 

*  M.  W.  Barr,  "  Mental  Defectives,"  1905. 

f  A.  Wizel,  Archiv  fiir  Psychiat.,  Band  xxxviii..  Heft  i. 


308  Idiots  Savants 

inmate  of  any  similar  institution  in  existence.  At  the  present 
time,  although  seventy-eight  years  of  age,  he  still  continues  to  be 
actively  engaged  in  his  workshop.  I  am  greatly  indebted  to  Dr. 
Caldecott  for  his  kindness  in  giving  me  permission  to  examine  this 
patient  and  his  wonderful  productions ;  also  for  freely  placing  at  my 
disposal  a  mass  of  particulars  and  photographs  regarding  him  which 
he  has  taken  great  trouble  to  collect. 

J.  H.  Pullen  was  born  in  the  year  1835.  The  family  history  is 
somewhat  scanty,  for  the  reason  that  the  only  informant  now 
available  is  the  patient's  sister;  but,  as  far  as  can  be  ascertained, 
the  parents  and  grandparents  were  steady,  sober,  hard-working 
people,  and  there  is  no  history  of  insanity,  epilepsy,  or  any  of  the 
usual  antecedents  of  primary  amentia.  The  parents,  however,  were 
first  cousins.  Of  thirteen  children  born  in  the  f9.mily,  six  died  in 
infancy,  and  of  the  remaining  seven  only  three  are  now  living.  It 
is  .extremely  interesting  to  note  that  another  brother  was  deaf  and 
dumb,  and  had  an  even  greater  aptitude  for  drawing  than  the 
patient;  he  died  in  Earlswood  Asylum  of  cancer  at  the  age  of 
thirty-five  years. 

There  are  no  particulars  as  to  the  age  at  which  the  patient  began 
to  walk,  but  he  did  not  talk  until  seven  years,  and  for  a  long  time 
only  uttered  the  word  "  muvver."  He  never  went  to  school,  as  no 
school  would  take  him.  He  showed  an  early  taste  for  drawing,  and 
used  to  spend  the  greater  part  of  his  time  at  this  occupation  or  in 
carving  ships  out  of  bits  of  firewood.  Such  instruction  as  he  had  he 
received  from  his  parents  and  brothers  and  sisters  at  home,  and  from 
these  he  learned  to  write  and  spell  the  names  of  simple  objects,  but 
this  was  practically  the  sum  total  of  his  scholastic  acquirements. 

Pullen  was  admitted  to  Earlswood  Asylum  at  the  age  of  fifteen 
years.  On  admission  he  was  found  to  be  active  and  well  grown, 
his  height  being  5  feet  y\  inches,  and  his  weight  9  stones  11  pounds. 
The  cranial  circumference  was  2if  inches.  He  was  described  as 
having  a  good  memory  and  power  of  imitation,  and  as  being  fond 
of  drawing  and  examining  how  things  were  made.  His  senses  of 
taste,  smell,  and  touch  were  good;  he  was  able  to  wash,  dress,  and 
take  care  of  his  person,  but  his  speech  was  very  imperfect  and  he 
was  very  deaf. 

He  was  put  to  work  in  the  carpenter's  shop,  and  soon  became 
an  expert  craftsman.  It  was  clear,  moreover,  that  he  possessed  a 
capacity  for  initiation,   imagination,  resource,   and  attention  far 


Plate  XXIII. 


IT;      V 


K        ., 


o  c 
1) 

1)    {U 
OJ    ? 


To  face  pagc-^oZ. 


The  Genius  of  Earls  wood  Asylum  309 

above  the  other  inmates,  and  in  consequence  he  was  allowed  con- 
siderable liberty  of  action  and  freedom  to  follow  his  own  bent. 
The  result,  after  sixty  years,  is  to  be  seen  in  the  fifty  to  sixty  crayon 
drawings,  the  carvings  in  ivory  and  wood,  and  the  wonderful  models 
of  ships  and  the  like,  which  to-day  adorn  the  walls  and  fill  the  two 
large  workrooms  placed  at  his  disposal  in  Earlswood  Asylum. 
Some  idea  of  his  skill  in  drawing  and  mechanical  invention  will  be 
gathered  from  the  accompanying  photographs  of  his  work  (Plates 
XXIII.,  XXIV.,  XXV.),  but,  as  Dr.  Caldecott  very  truly  says,  it  is 
difficult  by  this  means  to  really  appreciate  their  beauty,  to  do  which 
the  originals  must  be  seen. 

PuUen  has  designed  and  drawn  a  pictorial  history  of  his  life, 
which  shows  his  chief  occupations  between  the  years  1841  and  1873. 
A  reproduction  of  this  is  given  in  Fig.  55. 

One  of  the  most  wonderful  of  his  works,  and  the  one  of  which  he 
is  the  most  proud,  is  the  model  of  a  steamship  which  he  has  named 
the  Great  Eastern.    This,  I  think,  he  rightly  regards  as  his  magnum 
opus,  and  it  attracted  universal  admiration  at  the  Fisheries  Exhi- 
bition, where  it  was  shown  in  the  year  1883.     It  took  him  three 
years  and  three  months  to  complete,  and  every  detail,  including 
brass   anchors,    screw,    pulley-blocks,    and   copper   paddles,    were 
actually  made  by  the  patient  from  careful  drawings,  which  he 
prepared  beforehand.     The  planks  of  this  leviathan  are  fixed  to 
the  ribs  by  wooden  pins  to  the  number  of  nearly  a  million  and  a 
quarter.     AlLof  these  were  made  by  Pullen  in  a  special  instrument, 
which  in  turn  he  also  planned  and  made.     He  also  devised  and 
executed  a  strong  carriage  on  four  wheels  for  the  conveyance  of  the 
ship.    The  model  is  10  feet  long,  i8f  inches  wide,  and  13!  inches 
in  depth.     It  contains  5,585  copper  rivets,  and  there  are  thirteen 
lifeboats  hoisted  on  complete  davits,  each  of  which  is  a  perfectly 
finished  model.     It  is  fitted  with  paddles,  screw,  and  engines,  and 
it  contains  state  cabins,  which  are  decorated  and  furnished  with 
chairs,  tables,  beds,  and  bunks.     In  fact,  the  whole  thing  is  com- 
plete to  the  most  minute  detail,  and  will  bear  the  closest  inspection. 
(See  Fig.  59.)     He  has  invented  and  attached  an  arrangement  of 
pulleys  by  which  the  whole  upper  deck  may  be  raised  so  as  to  show 
the  parts  below.     I  believe  that  when  first  put  into  water  the  huge 
model  capsized,  but  that  has  since  been  remedied.     It  is  perhaps 
hardly  to  be  expected  that  a  person  with  no  knowledge  of  practical 
boat-building  should  succeed  in  making  a  vessel  that  would  be  really 


310 


Idiots  Savants 


navigable,  but  as  a  highly  finished  model  it  is  unmatched  in  its 
completeness. 

Another  of  PuUen's  productions  is  an  immense  but  most  beauti- 
fully finished  kite  in  the  form  of  a  ship  under  full  sail.  Another  is  a 
fully  rigged  man-of-war  of  the  old  wooden  type.  This  is  copper- 
riveted,  and  contains  forty-two  brass  cannon,  all  of  which  were 
made  by  the  patient.  The  rigging  contains  200  pulley-blocks,  all 
capable  of  working.  (See  Fig.  57.)  Another  production,  which 
testifies  to  his  imaginative  as  well  as  mechanical  faculty,  consists 
of  a  fantastic  barge  most  beautifully  carved  out  of  ivory,  ebony, 
and  various  fancy  woods.  Upon  the  prow  are  seated  four  angels 
carved  out  of  ivory,  whilst  the  stern  is  occupied  by  a  figure  of  His 
Satanic  Majesty.  There  are  twelve  oars,  beautifully  jointed,  and 
worked  mechanically  from  one  centre-rod. 

One  of  his  most  recent  pieces  of  work  is  the  representation  of  a 
monstrous  himian  form  about  13  feet  high.  This  black-bearded, 
terrible-looking  figiire  is  armed  with  a  gigantic  sword,  and  can  be 
made  to  perform  a  variety  of  movements,  such  as  opening  and 
shutting  the  mouth  and  eyes,  protruding  the  tongue,  rotating  the 
head,  raising  the  arms,  etc.,  by  means  of  a  most  elaborate  internal 
mechanism.  It  is  calculated  to  strike  terror  into  the  heart  of  any 
juvenile  beholder.  Of  this,  with  the  White  Knight,  he  may  truly 
say,  "  It's  my  own  invention." 

Other  productions  include  bookcases,  chairs,  tables,  work- 
benches, picture-frames,  and  the  like;  in  fact,  the  list  of  his  work 
during  the  sixty-three  years  he  has  been  in  the  asylum  would  alone 
fiU  several  pages  of  this  book. 

In  disposition  Pullen  is  usually  quiet,  well-behaved,  and  good- 
tempered,  and  he  seems  to  be  perfectly  happy  so  long  as  he  is 
allowed  to  work  out  his  own  ideas  when  and  how  he  pleases.  He  is 
intolerant  of  supervision,  inclined  to  be  suspicious  of  strangers,  and 
easily  affronted  by  injudicious  busybodies.  At  times  he  gets  a 
little  out  of  hand,  and  if  denied  requests  which  are  quite  unreason- 
able is  apt  to  become  sulky  or  passionate.  On  one  occasion  he 
threatened  to  blow  up  the  place  because  a  request  had  been  refused, 
and  it  is  quite  likel}'  that  he  would  have  attempted  to  do  so  had  he 
not  been  mollified.  On  another  occasion  he  did  actually  partially 
wreck  his  workshop  in  a  fit  of  passion.  Many  years  ago  there  was  a 
steward  of  the  asylum  to  whom  Pullen  took  a  violent  dislike,  and  he 
spent  many  days  planning  his  destruction.     This  culminated  in  the 


Plate  XXIV. 
PRODUCTIONS  OF  THE  "GENIUS"  OF  EARLSWOOD   ASYLUM. 


Fig.  56. —  \  crayon  cupv  of  the  celebrated  picture  "  Bolton  Abbey." 


Fig.  57. — A  full)--rigged  man-of-war  of  the  old  wooden  type,  and  carriayfe,  with  the  maker 
To  face  pa^c  310.] 


The  Genius  of  Earlswood  Asylum  311 

erection  over  the  door  of  a  most  diabolical  instrument,  which  was 
intended  to  guillotine  the  unfortunate  officer,  and  there  is  not  the 
slightest  doubt  that  it  would  have  done  so  had  it  not  gone  off  a 
fraction  of  a  second  too  late. 

He  once  became  enamoured  of  a  female  whom  he  had  chanced  to 
meet  outside  the  asylum.  Nothing  would  satisfy  him  but  that  he 
should  have  his  discharge  and  be  allowed  to  marry  her.  He  moped 
about,  utterly  refused  to  do  any  work  or  to  listen  to  argument  or  per- 
suasion, and  it  became  clear  that  the  position  was  critical.  A  happy 
inspiration  occurred  to  a  member  of  the  committee,  and  a  gorgeous 
naval  uniform,  resplendent  in  blue  and  gold,  was  procured.  PuUen 
was  invited  into  the  board-room  and  informed  that  his  case  had 
been  carefully  considered,  and  that  it  had  been  decided  to  accede  to 
his  request.  At  the  same  time  it  was  pointed  out  to  him  that  the 
committee  would  be  exceedingly  sorry  to  lose  his  valuable  services, 
and  that,  if  he  would  reconsider  the  matter,  they  would,  as  an 
alternative,  grant  him  a  commission  as  Admiral  in  the  Navy.  The 
uniform  was  then  shown  to  him  as  an  earnest  of  their  intention. 
This  was  too  much  for  Pullen;  he  took  the  uniform,  and  has  never 
since  alluded  to  the  subject  of  marriage.  This  uniform  he  usually 
dons  on  ceremonious  occasions.     (See  Fig.  54.) 

A  note  in  the  case-book  describes  him  as  "  the  quintessence  of 
self-conceit,"  and  a  consuming  vanity  and  almost  overwhelming 
sense  of  his  own  cleverness  and  importance  are  very  marked 
characteristics.  Whilst  showing  me  his  handiwork  he  frequently 
stopped  to  pat  his  head  and  say,  "Very  clever";  and  when  I 
produced  a  tape-measure  and  asked  permission  to  ascertain  the 
extent  of  his  cranial  capacity  he  was  delighted,  and  evidently 
regarded  me  as  a  very  sensible  fellow.  At  the  same  time,  in  spite 
of  his  childish  egotism,  he  is  by  no  means  deficient  in  some  power 
of  looking  after  himself,  and  on  several  occasions  he  has  been  found 
selling  privately  and  for  his  own  advantage  little  articles  he  has 
made.  Many  of  his  works  are  carried  out  under  the  real  or  pre- 
tended idea  that  he  has  a  commission  for  them  at  a  contract  price, 
and  this  childish  fancy,  as  well  as  his  extremely  limited  vocabulary, 
is  illustrated  by  his  private  memorandum-book,  the  photograph  of  a 
page  of  which  is  shown  in  Fig.  58. 

What  conclusion  are  we  to  come  to  regarding  the  causation  and 
pathology,  even  the  mental  status,  of  this  remarkable  man  ?  His 
powers  of  observation,  comparison,  attention,  memory,  will,  and 


312 


Idiots  Savants 


pertinacity,  are  extraordinary,  as  is  fully  shown  by  the  foregoing 
account ;  and  yet  he  is  obviously  too  childish,  and  at  the  same  time 
too  emotional,  unstable,  and  lacking  in  mental  balance,  to  make  any 
headway,  or  even  to  hold  his  own,  in  the  outside  world.  Without 
someone  to  stage-manage  him,  his  remarkable  gifts  would  never 
suffice  to  supply  him  with  the  necessities  of  life,  or  even  if  they  did,  he 
would  speedily  succumb  to  his  utter  want  of  ordinary  prudence  and 
foresight  and  his  defect  of  common  sense.  In  spite  of  his  delicacy 
of  manipulation  he  has  never  learned  to  read  or  write  beyond  the 
simplest  words  of  one  syllable.  He  can  understand  a  little  of  what 
is  said  to  him  by  lip-reading,  and  more  by  signs,  but,  beyond  a  few 
words,  nearly  all  that  he  says  in  reply  is  absolutely  unintelligible. 

My  own  conclusion,  based  upon  several  interviews  and  upon  the 
particulars  supplied  me  by  Dr.  Caldecott,  is  that  the  case  is  not  one 
of  primary  amentia  at  all,  but  that  it  should  really  be  classed  as  an 
example  of  mild  secondary  mental  deficiency  due  to  sense  depriva- 
tion (deafness).  Whether  this  deafness  is  the  result  of  a  congenital 
deficiency  of  the  auditory  mechanism  or  is  due  to  disease  I  am 
unable  to  say,  as  the  particulars  of  his  early  Ufe  are  unfortunately 
very  meagre ;  but  I  am  inclined  to  think  that  it  was  owing  to  this 
deprivation  that  he  was  refused  admission  to  school,  that  he  was  to 
a  great  extent  cut  off  from  intercourse  with  his  fellows,  and  that  he 
grew  up  uninstructed  in,  and  ignorant  of,  ordinary  scholastic  attain- 
ments and  the  ways  of  the  world.  Left  largely  to  himself,  his  amuse- 
ment consisted  in  copying  drawings  and  carving  bits  of  firewood,  as 
I  have  seen  in  other  cases  of  early  deafness.  His  isolated  condition 
caused  all  the  powers  of  his  mind  (which  do  not  seem  to  me  to  have 
been  intrinsically  defective)  to  be  devoted  to,  and  concentrated 
upon,  these  occupations,  with  the  result  that  he  developed  a  power 
of  copying  drawings,  of  carving  in  wood  (and  later  in  ivory),  and  a 
general  mechanical  dexterity  of  the  very  highest  order.  The  curious 
combination  of  extreme  ability  in  these  particulars,  with  his  general 
childish  simphcity,  his  egotism,  suspicion  of  strangers,  sullen  or 
passionate  outbreaks  if  thwarted,  and,  in  fact,  the  whole  of  his 
mental  characteristics,  are,  I  think,  explicable  on  this  view.  The 
condition  is  similar  in  kind,  although  differing  in  degree,  to  that 
frequently  seen  in  neglected  cases  of  congenital  deafness,  and  it  is 
not  greatly  dissimilar  to  that  of  some  non-idiotic  savants  who, 
absorbed  in  their  one  particular  subject,  have  gradually  lost  interest 
in,  and  severed  their  connexion  with,  the  outer  world. 


-   Plate  XXV. 
PRODUCTIONS   OF  THE  "GENIUS"  OF   EARLSWOOD  ASYLUM. 


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Fig.  5S. — Photograph  of  the  first  page  of  the  patient's  private  memorandum  book. 


I'iG.  59. — The  Great  Eastern  .  with  its  carriage,  as  exhibited  at  the 
Fisheries  Ivxhibition,  1SS3.     [Fur  description  see  Text.) 


CHAPTER  XV 
MORAL  DEFICIENCY  AND  CRIMINAL  AMENTS 

For  the  purpose  of  discussing  moral  deficiency  we  may  say  that 
morahty  is  social  virtue,  and  define  it  as  the  regulation  of  the 
conduct  of  the  individual  in  accordance  with  the  accepted  ethical 
code  of  the  community  of  which  he  is  a  member.  Perhaps  some 
persons  would  be  inclined  to  look  upon  conduct  as  being  dependent 
upon  spiritual  forces  which  transcend  mind  altogether,  and  there- 
fore removed  from  the  province  of  psychiatry.  But  whilst  there 
may  be  badness  as  well  as  madness,  the  general  tendency  of  modern 
investigations  is  undoubtedly  to  show  that  conduct  involves  mental 
activity,  and  that  where  this  is  disordered,  aberrations  of  conduct  and 
misconduct  are  apt  to  be  the  result.  This  view,  indeed,  is  one 
which  has  long  been  held  by  alienists,  and  the  person  who  has  lost 
the  power  of  regulating  his  conduct  in  the  moral  and  social  sphere 
is  spoken  of  ,as  suffering  from  "  moral  insanity,"*  although  the 
other  functions  of  his  mind  may  show  little  or  no  impairment. 
Similarly  the  person  who  has  never  developed  this  power  may  be 
said  to  be  morally  defective.  This  condition  of  moral  defect  is  now 
recognized  by  law,  and  the  Mental  Deficiency  Act  of  1913  defines 
moral  imbeciles  as  "  persons  who  from  an  early  age  display  some 
permanent  mental  defect  coupled  with  strong  vicious  or  criminal 
propensities  on  which  punishment  has  had  little  or  no  deterrent 
effect." 

The  use  of  the  term  "  moral  imbecile  "  is  in  accordance  with  the 
practice  which  has  obtained  for  many  years;  but  it  is  not  to  be 
assumed  that  persons  who  come  within  the  scope  of  this  definition 
necessarily  belong  to  the  imbecile  grade  of  mental  defect  as  we 

*  The  term  "  moral  insanity  "  was  first  used  by  Dr.  J.  C.  Prichard  in  1S35. 
The  condition  was  also  described  by  Dr.  Henry  IMaudsIey  in  186S,  and  is  now 
well  recognized  by  all  psychiatrists. 

3^3 


314     Moral  Deficiency  and  Criminal  Aments 

have  already  described  it.  Some  of  them  belong  to  this  grade; 
but  others  of  them  are  idiots,  and  the  majority  are  probably  merely 
feeble-minded.  In  order  to  obviate  confusion  it  would  in  my  opinion 
be  better  to  discontinue  the  use  of  the  term  imbecile  for  the  class  as 
a  whole,  and  to  substitute  that  of  moral  defective. 

Moral  defectives,  then,  or,  in  official  language,  "  moral  imbeciles," 
are  aments  whose  conduct  is  persistently  vicious  or  criminal.  But 
experience  shows  that  persons  coming  within  this  category  differ 
very  much,  both  in  the  nature  of  their  misconduct  and  in  their 
psychological  peculiarities,  and  hence,  if  only  for  purposes  of 
description,  some  classification  is  desirable.  Perhaps  the  best  way 
to  attain  this,  and  to  arrive  at  an  understanding  as  to  the  psycho- 
logical basis  of  their  misconduct,  is  to  consider  what  are  the  mental 
requisites  to  ethically  correct  conduct. 

One  of  the  chief  of  these  essentials  is  what  is  known  as  moral 
sense,  or  the  feeling  that  the  individual  is  under  certain  obhgations 
to  the  community  of  which  he  is  a  member.  There  are  four  chief 
"  senses  "  or  "  sentiments  "  which,  in  varying  proportions,  go  to 
make  up  the  mind  of  average  civilized  man.  These  may  be  described 
as  the  logical  or  intellectual,  the  religious,  the  cesthetic,  and  the 
moral  or  social.  The  logical  or  intellectual  sense  causes  us  to  test 
each  new  experience  by  the  light  of  our  previous  knowledge,  to 
criticize  and  carefully  compare,  and  to  accept  or  reject,  according  as 
our  judgment  affirms  it  to  be  true  or  untrue.  Such  a  type  of  mind 
is  said  to  be  essentially  rational.  The  religious  sense  implies  a 
conception  of  the  relationship  between  God  and  man.  It  is  largely 
made  up  of  the  emotions  of  awe,  reverence,  and  adoration,  and 
religion  has  been  well  defined  as  "  the  feeling  of  reverence  which 
men  entertain  toward  a  Supreme  Being,  or  to  any  order  of  beings 
conceived  by  them  as  demanding  reverence  from  the  possession  of 
superhuman  control  over  the  destiny  of  man  or  the  powers  of 
nature."*  The  sesthetic  sense  connotes  a  marked  appreciation  of 
all  that  is  beautiful  in  form,  colour,  sound,  etc.  Whilst,  lastly,  by 
the  moral  sense  is  meant  the  faculty  of  appreciating  the  obligations 
due  from  man  to  his  neighbours  as  component  units  of  society. 

Now,  these  various  senses  are  differently  developed  in  different 
individuals,  and  this  is  partly  a  result  of  special  hereditary  ten- 
dencies, and  partly  due  to  the  nature  of  their  early  environment. 
Some  persons  are  full  of  religious  feeling,  and  yet  absolutely  illogical, 

*  Ogilvie  and  Annandale,  "  Imperial  Dictionary." 


Moral  Deficiency  and  Criminal  Aments      315 

inartistic,  and  immoral.  I  have  no  doubt  that  most  medical  men 
have  met  with  individuals  of  this  type  who  are  most  fervent  leaders 
in  the  prayer  meeting,  most  enthusiastic  teachers  in  the  Sunday 
school,  most  highly  esteemed  as  local  preachers,  and  yet  guilty  of 
life-long  immorality  in  all  their  domestic  and  business  relationships. 
In  some  instances,  perhaps  in  most,  the  religious  fervour  is  assumed 
as  a  convenient  cloak  to  mask  their  social  shortcomings — it  is 
hjApocrisy  pure  and  simple ;  but  I  do  not  think  this  is  so  in  all,  and 
I  believe  there  may  exist  a  strongly  developed  religious  sense  with 
an  almost  complete  lack  of  moral  sense.  In  other  instances  the 
aesthetic  sentiment  may  be  highly  developed  whilst  the  logical  sense 
is  lacking,  and  this  is  the  case  with  many  individuals  who  have 
achieved  high  success  in  the  world  of  art.  Finally,  some  individuals 
may  possess  the  keenest  intellect  and  the  highest  logical  capacity 
and  yet  be  utterly  devoid  of  any  sense  of  religion,  art,  or  morality. 

There  can  be  no  doubt  that  human  conceptions  regarding  the 
obligations  of  the  individual  to  society  are  ever  changing  with  social 
development  and  the  progressive  evolution  of  the  mental  faculties. 
The  same  is  true  of  our  conceptions  of  religion  and  of  art.  The 
child  is  born  completely  devoid  of  any  of  these  senses,  and  their 
development  is  a  gradual  process  which  is  largely  dependent  upon 
the  nature  of  the  early  training  and  environment.  With  regard  to 
the  moral  sense,  it  seems  likely  that  it  is  only  by  the  constant  force 
of  example,  the  reiteration  of  precept,  and  the  infliction  of  punish- 
ment, that  the  child  gradually  acquires  a  sense  of  the  social  and 
legal  code  of  the  community  in  which  he  lives — a  standard  of  what 
is  right  and  what  is  wrong — and  is  thereby  enabled  to  conform  to 
moral  and  social  law.  This  result,  however,  is  not  entirely  due  to 
the  environment.  The  development  of  such  a  feeling  necessitates 
the  presence  of  an  innate  capacity  for  its  development,  and  there  is 
every  reason  for  thinking  that  some  persons  are  so  constituted  that 
they  are  utterly  devoid  of  this  potentiality.  Just  as  some  may  be 
fundamentally  incapable  of  acquiring  a  religious,  £esthetic,  or 
logical  feeling,  the  class  we  are  now  considering  are  fundamentally 
incapable  of  acquiring  a  moral  feeling. 

It  seems  likely  that  the  germ  of  the  religious  feeling  has  been 
present  in  man  from  a  very  early  period  of  his  existence.  The  most 
primitive  man,  with  any  affective  faculty  at  all,  could  hardly  fail  to 
be  impressed  and  awestruck  by  many  phenomena  of  Nature  which, 
to  his  mind,  could  only  be  brought  about  through  the  agency  of  all- 


3i6     Moral  Deficiency  and  Criminal  Aments 

powerful  spirits.  Hence  there  would  gradually  be  evolved  the 
religious  sense.  With  the  social  sense  it  is  different.  Primitive 
man  looked  more  to  his  own  individual  rights  than  to  those  of  his 
feUows,  and  the  social  feeling  only  arose  as  it  became  necessary  for 
the  whole  tribe  to  act  together  for  some  supreme  purpose.  It  is 
probably  to  the  necessity  for  common,  concerted  action  of  this  kind 
that  we  must  look  for  the  first  appearance  of  moral  feeUng.  Since 
then  it  has,  of  course,  undergone  great  transformation,  and  even 
in  the  past  few  hundred  years  an  immense  change  has  taken  place  in 
our  views  regarding  the  duties  of  man  to  his  neighbour  and  to  society. 
We  may  consider,  therefore,  that,  phylogenetically,  the  moral 
sense  is  the  latest  to  have  been  evolved,  and  it  also  appears  to  be 
the  latest  to  make  its  appearance  in  the  individual.  This  fact  is 
not  without  its  importance  in  considering  the  question  of  moral 
deficiency,  for  there  are  some  individuals  in  whom  this  feeling 
develops  so  late  in  life  as  to  give  rise  to  the  opinion  that  the  faculty 
is  absent  altogether.  I  have  known  persons  who,  during  childhood 
and  adolescence,  gave  every  indication  of  a  want  of  this  sense,  and 
yet  who  subsequently  evinced  high  civic  worth  and  character. 
But  although  egoism  is  a  much  stronger  and  more  deeply  ingrained 
feeling  in  most  of  us  than  is  altruism,  it  is  probable  that  the  pro- 
portion of  members  of  a  civilized  nation  who  are  fundamentally 
incapable  of  acquiring  the  social  sense  is  comparatively  small. 

Nevertheless  it  by  no  means  follows  that  the  conduct  of  persons 
who  are  lacking  in  this  sense  will  be  such  as  to  bring  them  within 
the  legal  definition  of  moral  deficiency  which  has  been  quoted;  it 
does  not  of  necessity  even  follow  that  they  will  be  guilty  of  offences 
against  the  legal  or  moral  code  of  the  community  at  all.  In  regard 
to  the  aesthetic  sense,  it  is  a  matter  of  experience  that  persons  may 
be  utterly  wanting  in  any  conception  of  beauty  or  harmony,  and 
yet  manage  to  avoid  infringing  the  canons  of  good  taste  by  a  rigid 
adherence  to  conventional  formalities;  it  is  equally  certain  that 
persons  who  are  wanting  in  any  real  religious  feeling  may  acquire  a 
reputation  for  piety  and  reverence  merely  as  a  result  of  their 
scrupulous  observance  of  religious  form  and  ceremony.  Such 
persons  have  no  artistic  or  religious  sense,  but  their  intelligence 
shows  them  the  propriety  of  conforming  to  a  certain  standard  recog- 
nized by  society,  and  the  defect  passes  unnoticed.  It  is  the  same 
with  a  defect  of  moral  sense.  Although  these  persons  have  no 
feelings  of  repugnance  or  shame  at  the  thought  of  a  criminal  or 


Moral   Deficiency  and  Criminal  Aments     317 

immoral  act,  and  although  they  cannot  appreciate  the  ethics  of  the 
Decalogue,  nevertheless  their  intelligence  tells  them  that  certain 
unpleasant  consequences,  in  the  shape  of  judicial  punishment  or  social 
censure,  will  follow  transgression,  and  this  suffices  to  keep  them 
within  the  prescribed  legal  and  social  code.  Their  moral  defect  is,  in 
fact,  latent.  But  although  latent  moral  defectives  of  this  kind  are 
not  of  necessity  actual  criminals,  they  may  well  be  described  as 
potential  criminals.  They  stand  in  the  same  relation  to  the  inmates 
of  our  prisons  as  do  the  psychopaths  or  potential  lunatics  to  the 
inmates  of  our  asylums,  or  the  improvident  to  the  inmates  of  our 
workhouses,  and  there  can  be  no  doubt  that  it  is  from  this  class  that 
one  section  of  our  criminals  is  drawn.  Although  there  is  no  intel- 
lectual defect,  and  such  persons  fully  realize  the  consequences  of 
detection,  yet  occasionally  the  gain  resulting  from  a  crime  or  act 
of  immoralitj^  appears  so  great,  and  the  likelihood  of  discovery  so 
small,  that,  moral  sense  being  absent,  they  deliberately  take  the 
risk.  On  the  other  hand,  should  there  be  any  coexisting  impair- 
ment of  the  intellect,  then  the  absence  of  moral  sense  will  almost 
inevitably  result  in  the  persistent  commission  of  criminal  and  anti- 
social acts  in  spite  of  punishment,  and  so  bring  the  person  within 
the  legal  definition  of  moral  defect. 

But  the  regulation  of  conduct  requires  something  more  than  a 
sense  of  the  rightness  or  wrongness  of  certain  acts ;  it  necessitates  the 
presence  of  sufficient  will  to  enable  the  person  to  follow  the  course 
which  he  knows  to  be  right,  and  to  eschew  that  which  he  knows 
to  be  wrong,  and  consequently  a  defect  of  will  may  lead  to  persistent 
wrongdoing,  and  bring  the  individual  within  the  category  of  legal 
moral  deficiency.  This  defect  of  will  may  make  itself  manifest 
under  two  separate  and  distinct  conditions.  In  the  first  of  these 
there  is  a  general  inertia;  the  individual  is  what  is  termed  "  wanting 
in  character,"  he  has  no  driving  force,  and  no  special  propensities 
for  either  good  or  evil.  He  is  facile,  he  simply  follows  the  line  of 
least  resistance,  and  is  swayed  this  way  or  that  according  to  the 
happenings  of  the  moment.  It  is  obvious  that  the  behaviour  of 
such  an  individual  will  be  entirely  dependent  upon  the  nature  of 
his  environment.  Within  the  seclusion  of  an  institution  in  which 
the  influence  is  entirely  good  he  may  lead  a  highly  moral,  even 
saintly,  life;  exposed  to  the  influence  and  machinations  of  evil- 
doers he  is  as  clay  in  the  hands  of  the  potter,  and  just  as  readily 
embarks  upon  a  career  of  crime. 


3 1 8      Moral  Deficiency  and  Criminal  Aments 

The  second  condition  in  which  a  defective  will  shows  itself  is 
in  an  inability  to  inhibit  immoral  and  antisocial  impulses.  The 
subject  of  morbid  impulses  belongs  rather  to  the  domain  of  mental 
perversion  (insanity)  than  mental  defect,  but  it  is  necessary  to 
make  a  brief  allusion  to  it  here  because  such  impulses  are  not  un- 
common in  aments,  and  they  lie  at  the  root  of  one  variety  of  criminal 
actions.  As  is  well  known,  impulses  of  this  kind  occur  with  toler- 
able frequency,  particularly  in  those  of  a  neurotic  constitution. 
Sometimes  the' impulse  is  to  count  a  definite  number  before  a  piece 
of  work,  such  as  writing  a  letter,  can  be  begun.  Sometimes  there  is 
an  irrepressible  impulse  to  repeat  some  particular  form  of  words; 
the  "  pink  trip  slip  for  a  three-cent  fare  "  of  Mark  Twain  is  a  well- 
known  illustration.  It  is  recorded  of  Dr.  Samuel  Johnson  that 
he  could  never  take  a  certain  walk  without  being  impelled  to  touch 
every  post  he  passed,  and  if  one  was  accidentally  missed  he  would 
go  back  to  touch  it.  A  patient  of  mine  at  one  time  had  such  a 
strong  impulse  to  throw  himself  under  the  engine  of  a  train  entering 
a  railway  station  that  he  never  dare  go  on  to  the  platform  until  the 
train  had  come  to  a  standstill.  Another  lady  patient  could  never 
take  a  railway  journey  without  the  feeling  that  she  must  throw 
herself  out  of  the  carriage  door.  On  one  occasion,  finding  herself 
left  alone  in  a  compartment,  she  was  compelled  to  seek  safety  by 
locking  herself  in  the  adjoining  lavatorj^  for  a  distance  of  forty 
miles.  So  far  as  society  is  concerned  impulses  of  this  kind  are  com 
paratively  harmless,  but  in  other  cases  they  take  the  form  of  an 
impulse  to  steal  (kleptomania) ;  to  set  things  on  fire,  such  as  com- 
mons, ■  heaths,  haystacks,  and  houses  (pyromania) ;  to  mutilate 
horses  and  cattle;  and,  by  no  means  rarel}',  to  commit  homicide. 
It  is  perhaps  a  moot  point  whether  one  should  regard  cases  of  this 
kind  as  dependent  upon  a  disorder  of  association  and  ideation,  or 
upon  a  defect  of  will.  It  may  be  that  the  impulses  have  such  an 
impelling  power  that  no  ordinary  volition  would  be  capable  of  with- 
standing them,  and  that  consequently  they  should  be  placed  in  a 
separate  category,  under  the  heading  of  "  morbid  impulses."  On 
the  other  hand,  they  are  frequently  resisted,  and  when  this  does  not 
occur  it  may  be  owing  to  a  defect  of  will.  However  this  may  be, 
there  is  no  doubt  that  recurrent  impulses  of  this  kind  occur  periodic- 
ally and  with  tolerable  frequency  in  certain  aments,  and  that  the 
inability  to  resist  them  brings  such  persons  within  the  class  of 
incorrigible  moral  defectives.     It   occasionally  happens   that  the 


Moral  Deficiency  and  Criminal"  Aments     319 

impulse  is  not  of  this  definite  character,  there  being  simply  a  general 
explosiveness  which  causes  the  individual  to  kick  over  the  traces  on 
any  and  every  occasion.  Lastly,  it  is  to  be  noted  that  neither  the 
presence  of  morbid  impulses  nor  of  defective  will  are  incompatible 
with  a  normally  developed  moral  sense. 

We  may  now  consider  to  what  these  various  mental  abnormalities 
are  due.  I  have  said  that  the  development  of  a  moral  sense,  whilst 
necessitating  a  certain  inherent  potentiality,  is  largely  dependent 
upon  the  nature  of  the  early  training  and  environment.  The  child 
who  grows  up  in  an  atmosphere  of  selfishness,  vice,  and  crime, 
cannot  be  expected  to  acquire  that  altruistic  feeling  which  is  the 
basis  of  moral  conduct.  For  him  lying,  thieving,  and  licentiousness 
are  meritorious  rather  than  immoral,  and  legal  punishment  is  only 
persecution  by  an  implacable  enemy.  It  is  the  same  with  defect 
of  will.  An  inherent  capacity  is  essential,  but  even  with  this  the 
child  who  has  only  to  express  a  wish  to  have  it  gratified,  and  who  is 
never  taught  to  control  his  impulses  whilst  young,  is  not  likely  at  a 
later  age  to  subjugate  his  feelings  and  desires  for  the  good  of  the 
community.  His  power  of  inhibition  is  undeveloped,  with  the 
result  that  his  lower  animal  feelings  have  full  play,  and  his  conduct 
becomes  vicious,  immoral,  and  antisocial. 

We  see,  therefore,  that  an  adverse  environment  may  lead  to  the 
formation  of  traits  which  in  their  effect  are  practically  indistinguish- 
able from  those  characterizing  the  morally  defective.  If  these  traits 
have  existed  too  long,  they  may  even  be  irreformable,  and  they  give 
rise  to  a  type  of  habitual  criminal  who  may  well  be  termed  a  sufferer 
from  acquired  or  secondary  moral  defect. 

On  the  other  hand,  there  are  many  persons  guilty  of  persistent 
immoral  and  antisocial  conduct  whose  upbringing  has  been  all  that 
could  be  desired.  They  have  been  reared  in  good  homes,  they  have 
been  exposed  to  good  influences,  and  everything  in  the  way  of 
precept,  example,  even  judicious  punishment,  has  been  tried  to 
make  them  conform  to  the  accepted  code  of  their  community.  But 
it  is  all  in  vain ;  they  remain  incorrigible,  and  it  can  only  be  assumed 
that  there  is  some  fundamental  brain  defect  which  prevents  them 
appreciating  the  difference  between  right  and  wrong,  or  which 
makes  it  impossible  for  them  to  avoid  the  commission  of  criminal 
and  immoral  acts.  The  presumption  is  that  this  defect  is  germinal 
in  origin,  and  this  is  supported  by  the  undoubted  fact  that  a  con- 
siderable number  of  these  persons  are  the  offspring  of  a  stock  many 


320      Moral  Deficiency  and  Criminal  Aments 

members  of  which  have  either  evinced  similar  propensities,  or  have 
shown  definite  indications  of  mental  abnormality.  This  variety 
may  be  termed  "  primary  moral  deficiency." 

One  of  the  most  interesting  studies  which  has  been  made  in  this 
field  during  recent  years  is  that  of  Gruhle.*  It  is  based  upon 
observations  made  upon  105  youths  in  the  reformatory  of  Flehingen, 
in  Baden,  and  the  history  of  each  case  is  given  in  detail.  As  the 
result  of  a  most  searching  analysis  into  all  the  factors  at  work,  Gruhle 
comes  to  the  conclusion  that  bad  environment  was  the  sole  or 
chief  factor  in  18  per  cent,  of  cases,  while  in  82  per  cent,  inborn 
disposition  was  solely  or  chiefly  responsible.  In  46  per  cent,  of 
cases  both  these  factors  were  considered  to  have  been  in  operation. 

It  is  to  be  noted  that  the  legal  definition  of  moral  defect  does  not 
apply  to  persons  who  are  vicious  or  criminal  only:  there  must  be 
permanent  mental  defect  as  well.  It  will,  therefore,  not  be  out  of 
place  to  consider  whether  persistent  moral  and  social  misconduct 
may  occur  without  intellectual  deficiency.  There  is  probably  no 
question  in  psychiatry  which  has  been  more  keenly  discussed,  and 
which  even  now  is  far  from  being  settled.  That  a  defect  of  moral 
sense  or  feeling  may  occur  without  any  intellectual  impairment  is, 
I  think,  undoubted,  and  this  is  explicable  on  the  view  previously 
suggested  that  the  ethical  sense  is  of  later  phyletic  evolution.  But 
such  persons,  as  already  remarked,  although  incapable  of  moral 
feeling,  are  yet  kept  from  the  commission  of  immoral  acts  by  their 
intellectual  recognition  of  the  consequences  which  may  follow,  and 
hence,  while  they  may  be  potential  criminals,  they  are  by  no  means 
necessarily  habitual  criminals.  The  undoubted  fact  that  many 
incorrigible  criminals  will  converse  upon  ordinary,  or  even  abstruse, 
subjects  in  an  exceedingly  intelligent  manner,  that  some  of  them 
are  actually  possessed  of  talents  beyond  the  common,  and  that  not 
a  few,  in  their  commission  of  offences  and  their  attempts  to  escape 
detection,  may  show  a  capacity,  alertness,  and  cunning  of  a  very 
high  order,  would  at  first  sight  impel  one  to  believe  in  the  existence 
of  a  condition  of  habitual  criminality  without  intellectual  impair- 
ment. But  the  satisfaction  resulting  from  the  acts  they  commit  is 
very  short-Hved;  it  is  inevitably  followed  by  serious  disadvantages 
in  the  form  of  punishment,  and  the  fact  that  they  are  utterly  unable 
to  control  their  evil  propensities  when  they  know  that  punishment 

*  H.  W.  Gruhle,  "  Die  Ursachen  der  jugendlichen  Verwahrlosung  und 
Kriminalitat, "  Heidelberger  Abhandlimgen,  1912,  Heft  i. 


Moral  Deficiency  and  Criminal  Aments     321 

has  followed  and  must  certainly  follow  again,  implies  a  serious 
defect  either  of  judgment  or  of  volition,  and  so  denotes  the  presence 
of  a  defect  other  than  that  of  mere  moral  sense.  Whilst,  therefore, 
I  quite  agree  with  Dr.  Maier,*  in  his  interesting  dissertation  on 
moral  idiocy,  that  there  may  be  a  congenital  inability  to  appreciate 
the  moral  conditions  of  the  environment  in  association  with  normal 
intellectual  tendencies — in  other  words,  that  an  individual  may  be 
intellectually  normal  and  yet  devoid  of  moral  sense — it  is  necessary 
to  recognize  that  there  is  a  difference  between  this  and  incorrigible 
criminality,  and  I  am  disposed  to  think  that  where  this  latter  occurs 
it  is  in  itself  indicative  of  some  degree  of  mental  impairment.  The 
precise  nature  of  this  mental  impairment  probably  varies  in  different 
cases.  In  some  it  may  be  a  defect  of  judgment,  in  others  a  weak- 
ness of  volition,  in  others  a  derangement  of  the  associative  and 
ideational  functions,  leading  to  the  presence  of  irresistible  impulses ; 
but  that  some  degree  of  mental  defect  is  present  can  hardly  be 
doubted,  since  the  individual  is  quite  incapable  of  foregoing  a 
momentary  satisfaction  for  a  permanent  advantage.  I  am  here 
speaking  only  of  incorrigible,  habitual  criminals. 

It  follows  from  this  that  persistent  misconduct  of  the  primary 
form — that  is,  that  form  which  is  due  to  innate  defect  of  potentiality, 
and  not  to  a  pernicious  upbringing — is  closely  related  to  amentia 
proper — that  it  is,  in  fact,  merely  a  special  variety  of  primary  mental 
deficiency.  Accordingly  we  should  expect  to  find  that  habitual 
criminals  are  the  result  of  similar  causes  and  possess  similar  physical 
characteristics  to  ordinary  aments.  It  must  be  admitted  that  this 
is  not  so  in  every  case.  I  have  met  persons  of  this  class  who,  in 
their  antecedents  and  physical  condition,  seemed  perfectly  normal ; 
indeed,  it  occasionally  happens  that  the  most  diabolical  cruelty  and 
the  most  violent  and  persistent  criminal  conduct  is  concealed 
under  an  extraordinarily  engaging  manner  and  appearance.  But 
these  cases  are  rare,  and  my  experience  is  that  most  persistent 
criminals  are  the  offspring  of  a  decidedly  neurotic  or  mentally 
abnormal  stock,  and  that  they  possess  many  characteristics  identical 
with  those  occurring  in  ordinary  aments. 

This  is  corroborated  by  numerous  investigations  which  have  been 
carried  out  in  recent  years  in  England,  America,  Italy,  France, 
Germany,  and  Russia  with  regard  to  the  physical  and  psychological 

*  H.  W.  Maier,  "  Ueber  moralische  Idiotie,"  Journal  fiir  Psychologic  und 
Neurologie,  1908,  Band  xiii. 


322     Moral  Deficiency  and  Criminal  Aments 

features  of  the  habitual  or  instinctive  criminal  class.  Many  par- 
ticulars of  these  are  given  in  Havelock  Ellis'  most  interesting  book, 
"  The  Criminal/'  and  to  some  of  them  we  may  here  refer. 

With  regard  to  the  brain,  the  results  do  not  enable  one  to  say 
that  a  special  "  criminal  type  "  exists,  but  nearly  all  the  inquirers 
are  agreed  that  anatomical  anomalies  indicative  of  irregular  or 
arrested  development  are  of  much  more  common  occurrence  than 
in  the  normal  population.  This  has  recently  been  well  shown  by 
the  interesting  study  of  Lattes*  upon  the  brains  of  fifty  criminals; 
whilst  Kaesf  found  agenetic  or  degenerative  changes  in  the  brains 
of  five  recidivists  which  he  examined.  The  same  is  true  of  the 
face,  jaws,  palate,  and  body  generally;  in  the  habitual  criminal 
stigmata  of  degeneracy  abound  just  as  they  do  in  the  ament.  The 
Anthropometric  Committee  of  the  British  Association  examined  over 
3,000  criminals,  and  found  them  about  2  inches  shorter  and  17 
pounds  lighter  than  the  average  English  population.  Baer  exam- 
ined 4,500  BerHn  criminals,  and  found  that  the  average  height  was 
decidedly  below  the  normal,  and  the  same  was  observed  by  Hamilton 
Wey  in  America.  Dr.  G.  Wilson,  in  a  paper  on  "  The  Moral  Im- 
becility of  Habitual  Criminals  as  exemplified  by  Cranial  Measure- 
ments," J  arrived  at  the  conclusion,  from  measurements  of  the  heads 
of  464  criminals,  that  habitual  thieves  had  well-marked  indications 
of  defective  cranial  development  associated  with  physical  deteriora- 
tion. Dr.  J.  Bruce  Thompson,§  in  a  summary  of  his  observations 
upon  over  5,000  prisoners,  pointed  out  the  great  prevalence  of 
mental  defect,  especially  amongst  the  juvenile  criminals,  and  also 
the  frequency  with  which  morbid  appearances  were  found  post- 
mortem. Professor  Lombroso,  in  his  book  "  L'  Uomo  Delinquente, 
came  to  the  conclusion,  on  anthropometrical  grounds,  that  the 
criminal  is  a  manifestation  of  degeneracy. 

Similarly  with  mental  characteristics.  Although  many  of  the 
criminal  class  appear  on  casual  examination  to  be  of  average  in- 
tellectual calibre,  there  is  abundant  evidence  to  show  that  a  large 
number  of  them  present  anomalies  similar  to  those  referred  to  in  our 
description  of  the  Feeble  Mind.  As  Havelock  Ellis  says,  "  On  the 
one  hand  he  is  stupid,  inexact,  lacking  in  forethought,  astoundingly 

*  Lattes,  Archiv.  di  Psychiat.,  1907,  vol.  xxviii.,  fasc.  i.,  ii. 
•j-   Kaes,  op.  cit. 

%  A  paper  read  before  the  British  Association  at  Exeter,  1869. 
§  Journal  of  Mental  Science,  iSjo. 


Moral  Deficiency  and   Criminal  Aments     323 

imprudent ;  on  the  other  hand  he  is  cunning,  hypocritical,  dehghting 
in  falsehood,  even  for  its  own  sake,  abounding  in  ruses."  iVnd  in 
■another  place,  "  The  criminal  in  some  of  his  most  characteristic 
manifestations  is  a  congenitally  weak-minded  person,  whose  ab- 
normality, whilst  by  no  means  leaving  the  mental  aptitudes  abso- 
lutely unimpaired,  chiefly  affects  the  feelings  and  volition,  so 
influencing  conduct  and  rendering  him  an  antisocial  element  in 
society."  Dr.  Maudsley,*  speaking  of  instinctive  criminals,  says: 
"  It  is  a  matter  of  observation  that  the  criminal  class  constitutes  a 
degenerate  or  morbid  variety  of  mankind  marked  by  peculiarly  low 
physical  and  mental  characteristics;"  whilst  Dr.  Nicholsonf  has 
also  pointed  out  the  great  prevalence  of  weak-mindedness,  with 
instability,  tendency  to  delusions,  insensibility,  and  emotional 
nature,  in  the  criminal  class.  A  similar  conclusion  is  arrived  at 
by  Gruhle  (in  the  work  already  quoted),  who  found  that  55  per 
cent,  of  juvenile  delinquents  were  psychically  abnormal,  whilst 
19  per  cent,  of  them  were  definitely  imbecile. 

Finally,  the  close  connexion  between  criminals  and  aments  is 
further  shown  by  the  antecedents  of  the  two  classes.  In  inquiring 
into  the  family  histories  of  members  of  the  habitual  criminal  class 
I  have  often  been  struck  by  the  fact  that,  although  some  of  them 
might  show  little  obvious  indication  of  mental  inferiority,  a  large 
number  of  them  came  of  a  neuropathic  stock,  and  possessed  brothers 
and  sisters  who  were  markedly  deficient.  Conversely,  in  examining 
aments,  I  have  often  found  that  their  brothers  or  sisters  were 
criminals.  In  dealing  with  the  inmates  of  prisons  it  is  often  ex- 
tremely difficult  to  obtain  a  family  history,  but  it  was  ascertained 
that,  of  233  prisoners  at  Auburn,  New  York,  at  least  23  per  cent, 
were  of  neurotic  (insane  and  epileptic)  origin.  Rossi  found  that  in 
71  criminals  there  were  5  insane  parents,  6  insane  brothers  and  sisters, 
and  14  cases  of  insanity  amongst  more  distant  relatives.  Kolk 
found  a  morbid  inheritance  in  46  per  cent,  of  criminals,  and 
]\Iarro  in  77  per  cent.  Sichard,  as  a  result  of  his  examination  of 
nearly  4,000  German  criminals,  found  that  there  was  an  insane, 
epileptic,  suicidal,  or  alcoholic  heredity  in  36-8  per  cent,  of  incen- 
diaries, 32  per  cent,  of  thieves,  287  per  cent,  of  sexual  offenders, 
and  23-6  per  cent,  of  sharpers. 

Lastly,  the  interesting  record  of  the  Juke  family,  which  was 

*  Maudsley,  "  Responsibility  in  Mental  Disease,"  1872. 
t  Nicholson,  Journal  of  Mental  Science,  1873-1875. 


324     Moral  Deficiency  and  Criminal  Aments 

compiled  by  R.  L.  Dugdale,*  well  shows  the  close  relationship 
existing  between  the  criminal  and  the  psychopath.  This  observer 
traced  the  descendants  of  one  morbid  couple  through  five  genera- 
tions to  the  number  of  709  individuals,  and  found  that  whilst  a 
small  proportion  were  honest  workers,  the  great  majority  were 
vagabonds,  paupers,  criminals,  and  prostitutes. 

I  think  these  facts  (and  I  have  only  referred  to  a  few  of  them) 
conclusively  show  that,  although  in  a  large  number  of  habitual  or 
instinctive  criminals  the  defect  maj^  appear  to  be  more  moral  than 
intellectual,  nevertheless  their  persistent  criminality  in  spite  of 
punishment,  as  well  as  the  many  features  the}-  possess  in  common 
with  the  true  aments,  are  a  sufficient  justification  for  our  considering 
them  as  being  closely  related  to,  indeed  actuaUy  suffering  from,  a 
mild  degree  of  mental  deficiency. 

Numerical  Incidence  of  Moral  Defectives. 

The  number  of  moral  defectives  (within  the  legal  meaning  of  the 
term)  resident  in  the  prisons  and  convict  establishments  of  the 
country  at  any  given  time  by  no  means  represents  the  total  number 
in  existence.  Many  will  have  just  been  discharged  and  be  found 
wandering  the  country;  whilst  others  will  be  temporarily  detained 
in  workhouses,  homes,  or  asylums.  This  makes  their  enumeration 
a  very  difficult  matter,  and  it  is  only  possible  to  give  an  approximate 
estimate.  Answering  a  question  in  the  House  of  Commons  on 
July  22,  1907,  the  Home  Secretary  said:  "  Both  in  local  and  convict 
prisons  those  prisoners  who  are  not  certifiabh'  insane,  but  are  unfit 
through  mental  deficiency  for  the  ordinary  penal  discipline,  form  a 
separate  class  and  are  specially  treated.  In  the  year  1906-07  the 
numbers  were — In  local  prisons,  355,  and  in  convict  prisons,  107.  .  .  . 
In  addition  to  those  so  classified,  there  are  other  prisoners  tem- 
porarily under  observation  to  ascertain  their  mental  state."  It  is 
obvious,  however,  that  these  figures  greatly  underestimate  the  real 
incidence;  in  fact,  they  refer  not  to  mental  or  moral  defect,  but  to 
amenability  to  prison  discipline,  which  is  a  totally  different  matter. 
The  reports  of  the  medical  investigators  to  the  Royal  Commission 
showed  that  on  an  average  at  least  10  per  cent,  of  the  prison  popu- 
lation were  defective,  but  this,  owing  to  the  nature  of  the  inquiry, 
is  probably  an  underestimate,  and  it  seems  likely  that  on  the  whole 

*  Dugdale's  book  is  a  most  careful  compilation,  and  well  worthy  of  study. 
A  fourth  edition  was  published  by  Putnams,  New  York,  in  1910. 


Description  325 

the  statement  of  Dr.  Parker  Wilson*  with  regard  to  Pentonville 
Prison  is  much  nearer  the  truth,  and  that  "  there  are  not  less  than 
20  per  cent,  of  the  prisoners  who  show  signs  of  mental  inefficiency." 
In  the  case  of  juvenile  prisoners  the  proportion  who  are  mentall}^ 
defective  is  much  higher,  and  Dr.  Wilson  found  that  of  389  admitted 
in  the  course  of  a  3^ear,  26  could  neither  read  nor  write,  328  only 
averaged  the  second  standard,  and  35  only  could  read  and  write  well. 
He  described  as  many  as  40  per  cent,  of  them  as  feeble-minded. 
It  seems  likely  that  the  nearest  approximation  to  the  true  incidence 
will  be  gained  by  approaching  the  question  from  another  standpoint, 
and  considering  what  proportion  of  the  mentally  defective  evince 
pronounced  criminal  and  antisocial  tendencies.  My  investigations 
in  Somersetshire  showed  that  this  proportion  was  10  per  cent.,  which 
corresponds  to  a  total  of  about  13,000  moral  defectives  in  England 
and  Wales  in  the  year  1906.  The  total  number  of  persons  tried 
for  indictable  offences  during  the  preceding  year  was  61,463;  on  the 
assumption  that  20  per  cent,  of  these  were  mentally  deficient,  the 
number  of  these  latter  would  be  a  little  over  12,000.  We  shall, 
therefore,  probably  not  be  far  wrong  in  saying  that  the  number  of 
persons  in  England  and  Wales  coming  within  the  legal  definition 
of  moral  defect  was  between  12,000  and  13,000  in  1906. 

Description. 

In  the  preceding  chapters  of  this  book  mental  defectives  have 
been  divided  into  certain  varieties,  and  the  classification  was  largely 
based  upon  the  presence  of  particular  pathological  or  clinical 
conditions.  But  the  outstanding  feature  of  moral  defectives,  to 
whichever  of  these  clinical  varieties  they  may  belong,  is  that  of 
incorrigible  misconduct,  and  if  any  further  subclassification  is  to 
be  made,  it  would  appear  most  desirable  that  it  should  rest  upon 
the  presence  of  any  peculiarities  in  this  respect.  Conduct,  no 
doubt,  is  the  outward  and  visible  manifestation  of  certain  internal 
brain  states,  and  hence  a  psychological  classification  would  probably 
be  the  most  scientific.  As  we  have  already  seen,  there  is  every 
reason  for  thinking  that  psychological  differences  do  exist:  that 
some  moral  defectives,  for  instance,  are  characterized  by  a  lack  of 
moral  sense,  others  by  a  feeble  will,  and  others  by  the  presence  of 
irresistible  morbid  impulses.     But  our  knowledge  of  the  psychology 

*  Parker   Wilson,   in   the   Report   of   Royal   Commission   on   the   Feeble- 
minded, 1908,  vol.  viii.,  p.  123. 


326     Moral  Deficiency  and  Criminal  Ainents 

of  this  condition  is  so  very  imperfect  that  I  feel  a  classification  on 
these  hnes  is  at  present  hardly  justifiable,  and  hence,  whilst  en- 
deavouring to  point  out  the  mental  correlation  that  exists,  I  shall 
confine  myself  to  classifying  these  cases  according  to  the  particular 
features  of  their  morbid  conduct. 

Considered  from  this  point  of  view,  I  think  that  moral  defectives 
may  be  divided  into  three  chief  varieties,  as  follows : 

1.  The  morally  perverse,  or  habitual  criminal  type. 

2.  The  facile  type. 

3.  The  explosive  type. 

In  addition  to  these,  it  is  to  be  noted  that  criminal  acts  are 
frequently  committed  by  aments  during  an  attack  of  insanity ;  but 
as  such  attacks  hardly  come  within  the  category  we  are  now  con- 
sidering, they  will  be  dealt  with  in  the  description  of  Insane  Aments. 
The  above  three  types  will  now  be  considered  in  order. 

1.  The  Morally  Perverse,  or  Habitual  Criminal  Type. 

The  persons  comprising  this  group  conform  most  strictly  to  the 
legal  definition  of  moral  defect  which  has  been  given,  inasmuch  as 
their  whole  lives  are  one  long  round  of  vice  and  crime,  from  which 
they  are  absolutely  undeterred  by  entreaty,  reason,  or  punishment. 
In  my  experience  they  commit  crimes,  not  because  they  are  deficient 
in  will  or  are  passionate  and  excitable,  like  those  to  be  presently 
considered,  but  because  they  are  either  possessed  of  ineradicable 
antisocial  propensities,  or  reaUy  cannot  appreciate  the  difference 
between  right  and  wrong.  They  are,  in  fact,  fundamentally  lacking 
in  moral  sense,  and  this,  together  with  the  defect  of  judgment 
which  is  always  present,  causes  them  to  be  absolutely  irreformable. 
The  condition  is  inborn,  and  consequently  shows  itself  in  the  earliest 
years.  As  children  they  wiU  commit  acts  of  almost  fiendish  cruelty 
to  animals  and  those  younger  than  themselves;  they  will  lie  when 
the  truth  would  answer  their  purpose  just  as  well  or  better;  they 
will  purloin  anything  which  comes  within  their  reach,  to  destroy 
it  or  throw  it  away  the  next  moment;  they  will  break  windows  and 
crockery,  set  fire  to  hayricks,  furniture,  or  anything  that  will  burn, 
and  take  a  malicious  delight  in  upsetting  a  baby  in  a  perambulator 
or  pushing  another  child  into  the  river;  in  short,  they  will  per- 
sistently act  in  such  a  way  as  to  be  a  terror  to  their  relatives  and 
the  whole  neighbourhood  in  which  they  live.     In  later  years  such 


Morally  Perverse,  or  Habitual  Criminal  Type     327 

persons  are  guilty  of  the  more  serious  crimes  of  incendiarism, 
train-wrecking,  criminal  assaults  upon  little  girls,  and  homicide, 
and  although  these  may  at  times  appear  to  be  sudden  and  un- 
premeditated, they  very  often  show  evidence  of  previous  delibera- 
tion and  plan,  and  sometimes  of  considerable  cunning  to  escape 
detection.  Their  whole  lives  consist  of  an  almost  unbroken  series 
of  offences,  in  many  cases  there  being  literally  scores  of  convictions, 
whilst  in  some  they  amount  to  hundreds;  they  are  the  definitely 
mentally  defective  habitual  criminals. 

At  the  same  time  it  is  important  to  remember  that  the  intel- 
lectual impairment,  as  judged  by  the  ordinary  standards,  may  be 
by  no  means  obvious.  Whilst  in  some  instances  it  is  absolutely 
impossible  to  keep  these  children  at  school,  in  consequence  of  which 
they  show  considerable  educational  arrears,  in  others  they  may 
attain  to  a  tolerable  proficiency;  and  a  few  evince  a  more  than 
average  degree  of  acquirement  in  some  particular  direction.  A 
certain  proportion  of  persons  of  this  type  are  markedly  insensitive 
to  pain,  and  such  will  suffer  severe  injuries  from  cuts,  burns,  etc., 
and  even  undergo  grave  surgical  operations  without  any  appearance 
that  they  feel  the  slightest  discomfort.  It  might  be  thought  that 
such  persistent  criminals  as  they  prove  themselves  to  be  would 
certainly  possess  a  degraded,  criminal  type  of  features;  but  although 
in  some  of  them  stigmata  of  degeneracy  are  present,  this  is  by  no 
means  always  the  case,  and  not  a  few  of  them  are  pleasant-looking 
plausibly  speaking  persons  who  would  seem  to  be  absolutely  in- 
capable of  committing  the  crimes  of  which  they  are  undoubtedly 
guilty.  Dr.  Shuttleworth*  mentions  "  three  nice-looking  children, 
sisters  and  brother,  formerly  under  his  care,  who  at  times  would 
appear  models  of  propriety,  while  at  others  they  had  all  the  charac- 
teristics of  little  demons.  With  innocent  expression  they  would 
furtively  accomplish  the  most  abominable  mischief,  and  after 
meekly  acknowledging  the  error  of  their  ways,  would  emphasize 
their  apology  by  a  missile  flung  at  the  head  of  the  person  who  had 
attempted  to  bring  them  to  repentance."  I  know  one  boy  who 
has  not  yet  reached  his  eighth  birthday,  but  he  has  already  been, 
expelled  from  school  because  nothing  was  safe  within  his  reach. 
He  has  a  vocabulary  equal  to  that  of  any  bargee,  and  he  steals 
eggs,  fruit,  money,  and  anything  he  can  lay  his  hands  on;  he  has 
already   burnt   two   hayricks   to   the   ground.     In   an   elementary 

*   Shuttleworth  and  Potts,  "  Mentally  Deficient  Cliildren,"  1910. 


328      Moral  Deficiency  and  Criminal  Aments 

school  of  a  provincial  town  I  came  across  three  children  of  this 
type  belonging  to  one  famih^  The  two  boj^s  were  onty  eight  and 
five  years  old  respectively,  and  the  girl  seven  years ;  but  the  school- 
master told  me  that  they  had  a  propensity  for  h'ing,  thieving,  and 
causing  trouble  generally,  the  like  of  which  he  had  never  met,  and 
that  nothing  seemed  to  deter  them.  They  were  all  mentally  defec- 
tive, and  I  was  informed  that  the  father  was  of  the  same  type,  and 
more  often  in  than  out  of  prison.  The  following  cases  are  further 
examples  of  this  class : 

George  P ,  a  mentalh'  defective  child,  aged  thirteen  and  a  half 

years,  attending  school  in  Standard  L  Power  of  reasoning  decidedly 
wanting,  but  alert  and  cunning,  and  always  getting  into  trouble. 
He  is  said  to  be  incorrigibly  lazy  at  school,  and  a  frequent  truant, 
and  the  schoolmaster  says  that  he  will  steal  and  lie  without  the 
least  compunction,  and  that  punishment  seems  to  be  without  the 
slightest  effect.  He  is  alwaj^s  ready  with  a  plausible  excuse,  and 
shows  a  precocious  amount  of  cunning  in  covering  up  his  misdeeds. 
A  short  time  ago  he  stole  the  schoolmistress'  gold  watch  from  its 
accustomed  place  on  her  desk.  It  was  not  missed  until  the  children 
had  left,  and  then  there  was  an  instant  hue  and  cry.  George, 
finding  himself  pursued,  secreted  the  watch  in  a  tree,  and  then 
submitted  himself  to  be  searched  with  an  air  of  complete  innocence. 
Unluckily,  however,  for  him,  the  manoeuvre  had  been  seen.  It. is 
interesting  to  note  that  this  boy's  father  is  just  the  same  (indeed, 
I  am  inclined  to  think  that  this  moral  perversion  is  often  heredi- 
tary). He  is  plausible  and  cunning,  and,  although  he  occasionally 
does  odd  jobs,  I  was  told  by  the  police  that  he  never  did  any  regular 
work,  and  that  the  greater  part  of  his  life  had  been  spent  in  prison 
for  such  offences  as  stealing,  poaching,  and  drunkenness.  When  I 
saw  him  he  had  just  returned  from  serving  a.  term  of  imprisonment 
for  poaching. 

An  extreme  instance  of  this  type  of  case  which  is  worth}^  of  note 
is  related  by  Dr.  Gray,  lately  physician  to  the  Ameer  of  Afghanistan, 
and  referred  to  by  Dr.  Mercier.*  It  is  that  of  a  man  "  who,  after 
having  had  first  his  right  hand,  and  subsequently  his  left  hand, 
struck  off  as  a  punishment  for  theft,  seized  with  his  stumps  and 
made  off  with  an  earthenware  pot  of  trifling  value  and  of  no  use 
whatever  to  him.  The  crime  was  \\itnessed  and  the  criminal  at 
once  arrested  and  taken  before  the  Ameer,  v.'ho  sentenced  him,  as 
*  Charles  Mercier,  "  Criminal  Responsibility,"  1905. 


Morally  Perverse,  or  Habitual  Criminal  Type      329 

he  must  have  expected,  to  be  hanged;  and  hanged  he  accordingly 
was."  Dr.  Mercier  also  mentions  the  case  of  a  cadet  at  Sandhurst, 
who  stole  the  boots  and  clothes  of  a  comrade,  although  he  was 
amply  supphed  by  his  father,  and  had  no  need  of  the  things  stolen. 
He  stole  them  without  any  concealment,  and  actually  wore  them 
in  the  presence  of  their  owner.  He  was  expelled,  and  on  his  return 
'home,  although  standing  in  awe  and  terror  of  his  father,  nevertheless 
cleared  the  latter's  dressing-table  of  its  ivory  brushes  and  silver 
furniture,  and  sold  them  to  a  passer-by  for  five  shillings. 

Quite  recently  I  was  consulted  with  regard  to  an  almost  precisely 
similar  case  in  the  shape  of  a  youth  at  a  public  school  who,  although 
liberally  supplied  from  home,  and  having  everything  he  needed, 
svstematically  purloined  his  companions'  property  of  every  de- 
scription. This  youth  was  by  no  means  unintelligent;  in  fact,  in 
several  subjects  he  occupied  a  high  place  in  his  form,  and  his 
general  appearance  and  conversation  were  so  prepossessing  that 
anyone  not  acquainted  with  the  type  would  almost  certainly  feel 
that  some  horrible  mistake  had  been  made.  His  only  observable 
peculiarities  consisted  of  a  somewhat  wandering  attention,  a  general 
restlessness,  and  several  little  tricks  such  as  constantly  putting  his 
hand  to  his  collar,  etc.  And  yet,  when  I  questioned  him  about  his 
misdeeds,  he  acknowledged  them  without  any  shame  or  concealment, 
and  I  found  that  he  had  been  expelled  from  two  other  schools  for 
similar  practices. 

Another  case  which  recently  came  under  my  observation  is  that 
of  an  exceedingly  handsome  young  woman  of  good  family  who  had 
been  brought  up  amid  every  refinement  and  who  lacked  nothing — 
but  moral  sense.  From  the  age  of  ten  years  she  would  pilfer  money 
from  her  mother  and  the  maids  in  the  house.  She  was  removed 
from  school  after  school  because  she  robbed  the  other  girls,  per- 
sistently hed,  and  spread  stories  without  the  slightest  foundation. 
She  invented  and  circulated  stories  regarding  herself  and  young 
men  which  caused  grave  family  scandals.  She  obtained  large  sums 
of  money  by  false  pretences  from  her  relatives  and  friends,  and 
on  several  occasions  went  out  in  the  middle  of  the  night  to  meet 
young  men  of  notoriously  bad  character.  At  the  age  of  twenty-two 
her  reputation  was  such  that  it  was  impossible  for  her  to  remain 
at  home,  and  she  was  boarded  out  under  strict  supervision.  But 
she  absented  herself,  committed  misconduct  with  at  least  two  men, 
and  developed  a  bad  attack  of  gonorrhoea.    Every  effort  was  made 


33°     Moral  Deficiency  and  Criminal  Aments 

to  appeal  to  her  sense  of  honour  and  her  love  for  her  family;  but  she 
seemed  not  only  incapable  of  reforming,  but  to  be  quite  insensible 
of  the  shame  and  disgrace  she  had  brought  upon  herself  and  her 
name.  She  admitted  to  me  that  she  saw  no  harm  in  what  she  had 
done,  and  affirmed  that  she  would  do  the  same  again  if  she  got  the 
chance.  The  girl  was  of  good  birth,  most  prepossessing  appearance, 
and  might  undoubtedly  have  made  a  good  match  and  enjoyed  a 
high  social  position,  and  the  sacrifice  of  these  can  only  be  looked 
upon  as  indicative  of  some  mental  deficiency;  but  I  must  confess 
that  no  other  defect  was  ascertainable  beyond  the  inference  of 
defective  judgment  to  be  drawn  from  her  persistent  misconduct, 
and  it  might  on  that  account  readily  be  held  that  she  was  uncerti- 
fiable  under  the  present  legal  definition  of  moral  defect. 

Finally,  as  further  examples  of  this  type  of  morally  defective 
person,  I  may  refer  to  the  foUowing  three  cases  culled  from  the 
newspapers  during  the  past  few  years,  all  of  which  were  reported 
to  be  mentally  defective. 

"  W.  K.,  a  ten-year-old  boy,  was  charged  at  Bow  Street  with 
attempted  pocket-picking  in  a  railwa^'-train.  The  boy  excused 
himself  by  saying  that  his  mother  had  pushed  him  into  the  train 
with  orders  to  rob  the  lady.  The  police  found  that  there  was  not 
a  tittle  of  evidence  to  support  the  lad's  statement,  and  an  officer 
from  the  school-board  reported  that  he  was  mentally  defective." 

"  T.  P. — Owing  to  the  extraordinary  series  of  grave  outrages 
committed  in  Nottinghamshire  and  the  immediate  district  during 
the  past  month,  much  importance  was  attached  to  a  case  which 
occupied  the  attention  of  the  Mansfield  Bench.  The  man  in  custody, 
a  labourer  named  T.  P.,  aged  twenty-three,  a  deaf-mute  of  weak 
intellect,  was  charged  with  feloniously  placing  a  wooden  gate  on  the 
Great  Central  line  at  Kirkby-in-Ashlield.  P.  has  been  in  the  habit 
of  sleeping  out,  although  his  reputed  place  of  abode  is  at  Sutton- 
in-Ashfield,  within  which  area  there  have  been  a  number  of  abortive 
attempts  at  train-wrecking.  In  addition,  the  neighbouring  parish 
churches  of  Kirkby  and  Annesley  have  been  destroyed  by  fire  upon 
successive  nights,  both  disasters  being  the  work  of  an  incendiary. 
Prisoner  was  apprehended  in  a  shed  at  some  brickworks.  He 
showed  the  police-officers  a  spot  on  the  railway  where  he  said  he 
placed  a  wooden  gate  on  the  rails.  Dr.  Gray,  who  had  examined 
prisoner,  gave  evidence  that  P.  was  a  lunatic  and  a  proper  person 
to  be  taken  charge  of.     Deputy-Chief-Constable  Harrop  said,  as 


Morally  Perverse,  or  Habitual  Criminal  Type      331 

accused  was  certified  insane,  no  evidence  would  be  offered.  The 
man  was  first  arrested  in  connexion  with  a  robbery  at  Alfreton 
railway-station,  and  the  proceeds  were  found  in  his  possession; 
other  robberies  on  the  railway  had  been  also  traced  to  him.  Prisoner 
took  witness  and  Police-Constable  Fryer  to  Sutton-in-Ashfield, 
and  across  some  fields  to  the  Great  Central  Railway  at  Kirkby, 
where  he  pointed  out  the  exact  spot  at  which  an  obstruction  had 
been  placed  on  the  line.  He  exhibited  great  satisfaction  when  a 
train  approached,  and  showed  where  he  had  obtained  the  gate  and 
had  hidden  himself  until  a  train  dashed  into  the  obstruction.  After- 
wards prisoner  showed  exactly  where  two  pairs  of  trolly-wheels 
and  a  wheelbarrow  attached  had  been  placed  on  the  line.  Ac- 
cused was  ordered  to  be  sent  to  a  lunatic  asylum." 

"  An  extraordinary  story  was  told  at  Waltham  Abbey  Police  Court 
yesterday  morning,  when  F.  C.  R.,  a  boy  ten  years  old,  was  charged 
with  being  beyond  the  control  of  his  parents.  The  boy's  mother  said 
that  he  had  torn  tiles  from  the  roof  of  the  house,  smashed  most  of 
the  windows,  and  wrecked  the  greenhouse  with  bricks.  He  had 
drenched  his  invalid  father  with  water  as  he  sat  helpless  in  his 
chair,  and  had  thrown  bricks  at  him.  The  boy  had  threatened  to 
stab  the  witness  and  a  woman  who  worked  for  her,  with  a  knife. 
He  had  climbed  to  the  roofs  of  outhouses,  wrenched  off  tiles  and 
thrown  them  at  her.  He  had  stolen  money  from  her  purse,  and  his 
language  was  so  dreadful  that  neighbours  had  to  close  doors  and 
windows  to  avoid  hearing  it.  Police-Sergeant  Maher  said  that  the 
boy  had  made  Chingford  Road  horrible  by  his  language.  Witness 
had  seen  the  parents'  house,  which  was  a  perfect  wreck  on  account 
of  the  boy's  depredations.  He  produced  two  half-bricks  which  the 
boy  had  thrown  at  his  father.  The  Bench  remanded  the  lad  to  the 
workhouse  with  a  view  to  his  committal  to  an  industrial  school." 


2.  The  Facile  Type. 

In  this  type  of  morally  defective  person  the  commission  of  crimes 
and  acts  of  immorality  does  not  appear  to  be  so  much  due  to  any 
want  of  appreciation  of  the  difference  between  right  and  wrong,  or 
to  any  pronounced  criminal  propensities,  as  to  the  fact  that  the 
individuals  are  so  lacking  in  will  power  as  to  be  unable  to  steer 
a  right  course  against  resistance;  they  must  go  with  the  stream,  and 
hence  the  extent  of  their  criminality  is  dependent  upon  the  nature 


332     Moral  Deficiency  and  Criminal  Aments 

of  their  environment.  If  this  is  good,  thev  mav  lead  placid,  con- 
tented, harmless  lives,  and  these  persons  are  usually  obedient, 
well-behaved,  and  industrious  workers  nat^W'the  supervision  of 
an  institution,  and  they  are  readily  ame%i)T:!£^to  the  discipline  of 
prison  life.  Amid  bad  surroundings,  howev^gj,  the^^jreadily  succumb 
to  the  wiles  of  the  vicious,  and  become  the  dupes^.and  tools  of  the 
evil-disposed ;  and  under  these  circumstances «nfay  be  led  to  commit 
ver}^  serious  offences.  Perhaps,  strictly  speaking,  they  should 
hardly  be  regarded  as  morally  defective,  since  their  chief  defect  is  a 
mental  one,  but  since  their  facile  disposition  so  readily  predisposes 
them  to  crime,  they  comprise  a  variety  of  defective  criminals. 

These  persons,  unlike  the  class  we  have  just  referred  to,  do  not 
commonly  cause  much  trouble  until  adolescence  is  reached,  although 
instances  occur  in  which  even  as  children  they  have  been  instigated 
to  the  commission  of  offences  b}-  their  companions.  With  the 
appearance  of  adolescence,  however,  and  the  consequent  diminu- 
tion of  parental  restraint,  their  facilitv  soon  makes  itself  manifest, 
with  the  result  that  they  are  speedily  in  trouble. 

I  am  disposed  to  think  that  the  majority  of  this  type  are  females, 
and  the  first  lapse  is  usually  in  a  sexual  direction.  I  have  met 
\\ith  not  a  few  instances  where  a  feeble-minded  girl  of  this  kind, 
of  gentle  birth,  has,  before  the  age  of  maturity,  given  birth  to  an 
illegitimate  child;  whilst  in  the  working  classes  such  an  occurrence 
is  exceedingly  common.  ]\Iy  experience  is  that  about  half  the  girls 
admitted  into  Magdalen  Homes  on  account  of  a  "  first  fall,"  or  of 
the  extreme  probability  of  such  happening,  are  of  this  facile  feeble- 
minded type,  and  it  is  likely  that  a  considerable  proportion  of 
prostitutes  belong  to  the  same  class.  But  the  class  is  by  no  means 
composed  entirely  of  females,  and  there  are  not  a  few  mentall}- 
defective  youths  of  the  same  facile  disposition  who  readily  drift  into 
a  life  of  persistent  crime  in  the  absence  of  adequate  supervision. 
In  former  days  there  can  be  no  doubt  that  such  persons  were  fre- 
quently utilized  as  catspaws  by  professional  criminals  of  stronger 
intellect,  and  although  it  is  likely  that  the  number  of  persons  so^ 
made  use  of  has  considerably  diminished  during  recent  years,  our 
police  courts  show  that  even  to-day  such  feeble-minded  dupes  are 
by  no  means  unknown. 

The  following  are  illustrative  cases : 

Rose  T ,  a  well-grown,  pleasant-featured  girl  of  twent}'  j^ears. 

She  left  school  at  the  age  of  fifteen,  but  was  onlv  in  the   second 


The  Facile  Type  333 

standard,  and  wa^ 'always  regarded  as  "not  exactly."  On  the 
whole  her  conduot  at  school  was  good,  but  the  schoolmistress  said 
she  seemed  very'weak-willed  and  was  readily  persuaded  to  do  silly 
things  by  childr^much  younger  than  herself.  At  the  age  of  seven- 
teen she  was  admitted  into  a  rescue  home  in  a  pregnant  condition, 
and  it  appeared  that  for  months  past  she  had  been  walking  out  at 
night  with  most  of  the  boys  of  the  village  in  turn.  After  her  con- 
finement she  was  placed  in  a  training  home,  and  proved  herself 
such  a  cheerful,  willing  worker  that  in  a  short  period  a  place  in 
service  was  found  for  her.  Unfortunately  she  seems  to  have  got 
into  bad  company  during  her  evenings  out,  and  she  was  discharged 
from  her  situation  in  consequence  of  returning  very  late  one  night 
in  a  state  of  intoxication.  Upon  leaving  she  seems  to  have  been 
persuaded  by  her  companions  to  take  lodgings  with  them,  and  she 
was  soon  fully  embarked  upon  a  career  of  prostitution  and  crime. 
She  was  repeatedly  in  the  hands  of  the  pohce  for  drunkenness  and 
using  obscene  language,  and  on  several  occasions  served  short  terms 
of  imprisonment  for  petty  larceny.  The  police  were  of  opinion 
that  she  was  simply  a  tool  in  the  hands  of  the  female  with  whom 
she  lodged,  and  that  the  latter  lived  upon  her  pickings  and  stealings 
and  immoral  earnings;  but  this  woman  was  too  astute  to  be  caught. 
When  I  examined  this  girl'  she  was  obviously  very  weak-willed, 
irresponsible,  and  amenable  to  almost  any  suggestion;  her  judgment 
was  feeble,  and  her  ideas,  speech,  and  general  appearance  childish ; 
but  it  is  quite  likely  that  many  magistrates  would  doubt  whether 
there  was  sufficient  evidence  of  permanent  mental  defect  to  justify 
her  certification  as  a  moral  imbecile  under  the  Act. 

George  A ,  a  feeble-minded,  undersized  youth  with  a  slouching 

walk,  furtive  demeanour,  and  physiognomy  typical  of  mental  defect. 
He  answers  questions  in  a  simple,  childish  manner,  and  gives 
information  regarding  his  past  life  willingly  and  without  any  ap- 
pearance of  shame  or  concern;  his  memory,  however,  is  a  little 
defective,  and  his  account  is  at  times  confused  and  incoherent.  He 
cannot  read,  write,  or  sum,  but  he  is  quite  capable  of  useful  work 
under  supervision,  and  his  conduct  in  prison  (where  I  saw  him)  is 
good.  The  youth  knows  nothing  about  his  parents,  and  little  about 
his  early  life  beyond  the  fact  that  he  was  brought  up  in  an  industrial 
school,  and  thence  put  to  work  on  a  farm.  He  ran  away  because  he 
wanted  a  change,  and,  after  tramping  about  for  a  time,  eventually 
got  employment  on  another  farm.    He  ran  away  from  here  because 


334     Moral  Deficiency  and  Criminal  Aments 

he  was  discovered  committing  acts  of  indecency  vnih  the  cattle. 
He  then  tramped  about,  and  was  frequently  in  and  out  of  work- 
houses. He  was  convicted  with  several  others  of  stealing  lead, 
and  served  a  term  of  imprisonment.  After  this  he  again  tramped 
the  country,  spending  most  of  his  time  between  the  prison  and  the 
workhouse.  He  is  now  in  for  setting  fire  to  a  rick,  for  which  act  he 
is  unable  to  give  any  reason  beyond  that  he  was  told  to  do  it  by 
some  people  he  met  (tramps)  on  the  road. 


3.  The  Explosive  Type. 

I  have  termed  this  the  "  explosive  type  "  for  the  reason  that 
when  misconduct  occurs  it  is  of  the  nature  of  a  sudden,  violent 
storm  closely  resembling  the  motor  convulsions  of  an  epileptic. 
There  is  no  defective  appreciation  of  right  and  wrong ;  indeed,  these 
persons  often  manifest  contrition  at  the  acts  they  have  committed. 
The  wrongdoing  seems  to  be  simply  the  result  of  a  sudden  impulse 
which  they  are  unable  to  resist.  It  is  probable  that  this  results 
partly  from  a  lack  of  inhibition  and  partly  from  a  hypersensitivity, 
whereby  certain  feelings  and  ideas  rapidly  develop  a  dominating 
force.  However  this  may  be,  the  sudden  violence  of  the  acts, 
without  any  premeditation,  indicates  the  sudden,  excessive,  tem- 
porary liberation  of  nervous  energy  very  similar  to  that  occurring 
in  epilepsy,  and  the  cases  may  well  be  looked  upon  as  examples  of 
psychic  epileps}'.  There  is  a  further  resemblance  in  that,  like 
many  of  the  ordinary  epileptics,  these  persons  are  often  extremeh' 
obstinate,  intolerant  of  contradiction,  and  inclined  to  be  very 
suspicious;  whilst  their  mental  constitution  is  so  unstable  that 
they  will  often  suddenly  pass  from  a  state  of  what  appears  to  be 
perfect  calm  and  indifference  to  one  of  raving,  uncontrollable  inry. 
At  the  same  time  ordinary  epileptic  fits  are  not  common  in  the 
class. 

It  is  obvious  that  aments  of  this  unstable  type  are  extremeh' 
untrustworthy  and  dangerous,  and  they  consequently  comprise  a 
considerable  proportion  of  those  mental  defectives  who  commit 
criminal  acts.  Their  instability  will  usually  have  been  evident  from 
childhood,  although  in  a  few  cases  it  may  not  attract  marked  atten- 
tion until  puberty  or  adolescence  is  reached.  Their  misconduct  is 
undeterred  by  punishment,  which  indeed  often  onh^  makes  them 
morose  and  more  intractable,  and  this,  together  with  their  Intel- 


The  Explosive  Type  335 

lectual  defect,  brings  them  within  the  legal  definition  of  moral 
defect  which  has  been  quoted.  The  character  of  their  offences 
varies  very  considerably.  In  their  ordinary  moments  their  in- 
stability makes  them  prone  to  commit  acts  of  destruction,  to  fight- 
ing, brawling,  and  disorderly  conduct;  whilst  in  their  paroxysms 
there  is  hardly  any  crime  of  which  they  may  not  be  capable.  Feeble- 
minded persons  in  general  are  very  intolerant  of  alcohol,  but  its 
effects  seem  to  be  especially  marked  upon  the  type  we  are  now 
considering.  I  remember  one  youth  in  a  country  village  who  used 
to  be  repeatedly  pUed  with  cider  by  the  yokels  of  the  place  in  order 
that  they  might  be  amused  by  his  furious  excitement,  pretty  much 
in  the  same  way  as  a  bull  is  baited  in  the  ring.  The  following  are 
examples  of  the  type : 

Thomas  B ,  a  feeble-minded  young  man,  twenty-five  years  of 

age,  with  numerous  stigmata  of  degeneracy.  He  could  never  learn 
at  school,  and  afterwards  could  not  keep  his  situations.  At  the 
age  of  twenty-three  he  became  insane,  and  was  sent  to  the  asylum 
for  six  months.  Shortly  after  discharge  he  was  apprehended  for 
sleeping  out,  and  served  seven  days'  imprisonment.  He  had  only 
been  out  a  few  weeks  when  he  attempted  rape  on  a  small  girl  whom 
he  met  in  the  road.  For  this  he  was  sentenced  to  two  months' 
hard  labour.  On  being  liberated  he  became  very  violent  and 
aggressive,  and  threatened  to  cut  his  mother's  throat.  He  was  again 
sent  to  the  asylum,  and  discharged  in  six  months.  He  is  now  living 
at  home,  and  works  occasionally  in  the  factory;  but  his  mother 
says  that  he  cannot  be  depended  upon,  that  some  days  he  refuses 
to  get  out  of  bed,  and  is  at  times  so  violent  that  she  is  afraid  to 
have  him  in  the  house.  He  is  a  powerful  fellow,  who  should  be 
capable  of  hard  work  could  he  be  controlled. 

Alfred  L ,  a  feeble-minded  man  of  twenty-eight  years.     He 

is  now  occupied  cracking  stones,  and  does  occasional  work  on  farms 
when  he  can  get  it;  but  he  is  very  unstable,  at  times  being  noisy, 
excitable,  quarrelsome,  and  absolutely  refusing  to  do  any  work. 
He  has  been  imprisoned  at  least  six  times  for  such  offences  as 
drunkenness,  fighting,  stealing,  and  setting  fire  to  gorse,  and  is 
known  and  dreaded  for  miles  round  as  a  regular  nuisance. 

H.  A.,  a  feeble-minded  deaf-mute,  was  charged  with  stabbing 
his  sister.  The  prosecutrix  said  that  he  had  never  been  quite  right 
in  his  mind,  and  that  she  had  always  treated  him  as  a  child,  but 
that  he  was  no  trouble  if  he  did  not  get  into  drink.     The  medical 


336     Moral  Deficiency  and  Criminal  Aments 

officer  of  the  prison  certified  him  as  being  of  weak  mind  and  likely 
to  be  easily  affected  by  drink,  but  he  could  not  certify  him  as  insane. 
The  charge  was  reduced  to  one  of  common  assault,  and  the  magis- 
trate "  thought  it  would  be  good  for  the  youth  to  go  to  prison,  and 
committed  him  for  two  months  "  ! 

I  have  no  personal  knowledge  of  the  following  case,  but  as  it 
seems  undoubtedly  to  come  within  the  class  we  are  now  considering, 
and  to  be  of  a  somewhat  extraordinary  nature,  it  seems  worthy  of 
mention  in  this  place:* 

"  Six  murders  at  the  age  of  thirteen  is  the  remarkable  record 
claimed  by  Ida  Schnell,  whose  case  is  at  present  being  investigated 
at  Munich.  The  girl  had  been  in  service  with  a  number  of  different 
families  as  nursemaid,  and  no  suspicion  seems  to  have  arisen  against 
her  till  after  the  sixth  infant  entrusted  to  her  care  had  died  a  sudden 
and  mysterious  death.  Even  then  it  was  only  after  the  baby  had 
been  buried  that  it  appears  to  have  struck  anyone  that  there  was 
something  sinister  in  the  circumstance  that  her  nursing  had  been 
associated  with  mortality  of  so  remarkable  a  character.  It  was 
finally  decided  to  exhume  the  body  of  the  last  of  her  charges,  the 
fourteen-day-old  son  of  a  peasant  proprietor  of  Ampermoching, 
near  Munich.  The  corpse  was  taken  from  the  coffin  yesterday 
afternoon,  and  examination  showed  that  death  had  been  caused  by 
perforation  of  the  yet  soft  infantile  skull  with  some  sharp  instru- 
ment. "Schnell  was  at  once  arrested  and  closely  questioned.  At 
first  she  strenuously  denied  having  caused  the  child's  death  and 
protested  that  she  had  much  too  gentle  a  nature  to  harm  the  infant 
in  any  way.  Under  cross-examination,  however,  she  broke  down, 
and  admitted  that  she  had  killed  not  only  the  baby  whose  body 
had  been  exhumed,  but  four  others  for  whom  she  had  been  engaged 
as  nurse.  She  confessed  further  that  she  had  taken  the  lives  of  these 
infants  by  plunging  a  hairpin  into  the  lower  part  of  the  back  of  their 
heads  till  they  ceased  to  cry.  Asked  as  to  her  motive,  the  girl  said 
that  the  crying  of  the  infants  roused  in  her  unconquerable  revulsion, 
and  excited  her  to  such  a  degree  that  she  lost  all  control  over  herself, 
and  would  do  anything  to  make  them  quiet.  This  morning  she 
confessed  to  the  sixth  murder.  The  parents  of  one  of  her  victims 
reside  in  Munich  itself,  the  others  in  small  places  in  the  vicinity. 
Schnell,  who  will  be  fourteen  next  month,  is  physicallj'  well  devel- 
oped for  her  age,  but  rather  dull-witted.  Her  father  is  dead,  but 
*  Verbatim  from  the  Daily  Telegraph,  October  18,  1907. 


The  Explosive  Type  337 

she  has  a  stepfather,  who  is  a  day  labourer  at  Schleissheim,  to  the 
north  of  Munich.  Her  series  of  murders  was  only  rendered  possible 
by  the  fact,  which  will  be  a  revelation  to  many,  that  in  Bavaria 
death  certificates  are  frequently,  and  in  the  country  districts  always, 
granted  by  laymen.  It  is  said  that  a  doctor  would  at  once  have 
noticed  the  wounds  caused  by  the  hairpin." 

Other  Criminal  Aments. — Hitherto  we  have  considered  only  those 
cases  of  mental  defect  which  are  accompanied  by  such  persistent 
vice  and  criminal  conduct  as  to  bring  the  persons  within  the  legal 
•definition  of  moral  imbecility,  or,  as  I  prefer  to  call  it,  moral  defect. 
It  is  necessary  to  point  out,  however,  that  these  are  by  no  means 
the  only  criminal  aments.  Mentally  defective  persons  may,  and 
frequently  do,  commit  serious  offences  during  an  attack  of  insanity, 
and  cases  of  this  kind  will  be  described  in  the  chapter  dealing  with 
Insane  Aments.  Also  many  aments  who  are  neither  insane  nor 
possess  vicious  or  criminal  propensities  may  be  guilty  of  occasional 
crimes  of  a  very  serious  nature.  Thus,  a  feeble-minded  young  man 
of  nineteen  years  attempted  to  wreck  a  train  by  placing  a  large 
coil  of  electric  wire  on  the  line.  No  motive  whatever  could  be 
assigned  for  the  act.  A  feeble-minded  girl  aged  seventeen,  living 
in  a  small  village,  was  frequently  jeered  at  by  the  boys  of  the  place. 
One  day  she  called  one  of  them  to  her,  and  told  him  to  shut  his 
eyes  and  open  his  mouth  and  see  what  the  King  would  send  him. 
He  did  so,  and  the  girl  promptly  drew  a  razor  across  his  throat, 
partially  severing  his  windpipe.  Another  feeble-minded  boy  of 
sixteen  years  drowned  a  child  of  three  by  pushing  him  into  a  dyke. 
Such  examples  might  be  multiplied  almost  indefinitely,  but  they 
serve  to  show  that  the  irresponsibility  and  lack  of  judgment  which 
is  such  a  characteristic  of  aments  may  readily  cause  them  to  commit 
serious  crimes  even  in  the  absence  of  persistent  vicious  propensities. 

This  brings  us  to  the  consideration  of  the  important  question  of 

The  Criminal  Responsibility  of  Aments. 

The  law  of  England  has  long  recognized  that  persons  suffering 
from  certain  forms  of  mental  disease  should  not  be  held  accountable 
for  their  actions,  and  into  this  category  come  idiots  and  pronounced 
imbeciles,  or  any  person  who,  in  the  words  of  Mr.  Justice  Tracey 
(1723),  knows  what  he  is  doing  "  no  more  than  an  infant,  a  brute, 
or  a  wild  beast."  By  the  provisions  of  the  Mental  Deficiency  Act 
it  would  appear  that  a  similar  protection  is  now  afforded  to  any 


338      Moral  Deficiency  and  Criminal  Aments 

mentally  defective  person,  since  it  is  laid  down  that  a  defective 
person  found  guilty  of  any  criminal  offence  may  be  dealt  with 
under  the  Act  by  being  sent  to  an  institution  for  defectives  instead 
of  to  a  penal  establishment.  The  use  of  the  word  may,  and  not 
shall,  however,  still  leaves  his  position  somewhat  ambiguous  and  in 
the  hands  of  the  judge,  so  that  the  criminal  responsibihty  of  aments, 
as  well  as  of  the  insane,  can  by  no  means  be  said  to  be  clearly  defined. 
There  are  certain  precedents  and  rulings  which  are  usually  followed 
in  such  cases,  but  in  any  particular  instance  the  fact  of  the  responsi- 
bility or  otherwise  of  the  accused  is  a  question  for  the  jury  to  decide 
upon  the  evidence  presented  to  them.  Criminal  offences  in  which 
this  question  of  responsibility  is  raised  are  exceedingly  common, 
and  it  is  plainly  the  duty  of  the  members  of  our  profession,  wha 
alone  can  form  a  correct  estimate  as  to  the  extent  to  which  conduct 
is  likely  to  be  influenced  by  mental  deficiencj^  or  disease,  to  formu- 
late general  principles,  and  to  give  their  opinion  regarding  the  mental 
condition  of  any  particular  accused  person  in  order  that  the  jury 
may  arrive  at  this  decision.  These  general  principles,  however, 
must  be  just,  and  whilst  protecting  those  who  are  really  irrespon- 
sible from  undeserved  punishment,  they  must  also  protect  society 
against  the  escape  from  punishment  of  those  who,  even  if  mentally 
deficient,  are  rightly  accountable  for  their  actions. 

The  ruhngs  of  EngHsh  Courts  at  the  present  time  are  generally 
based  upon  the  replies  of  the  fifteen  Judges  to  the  House  of  Lords 
in  the  middle  of  the  last  century.  Briefly,  it  may  be  stated  that, 
for  an  accused  person  to  be  held  irresponsible  on  the  ground  of 
insanity,  it  must  be  shown  that  he  was  of  diseased  mind,  and  that 
at  the  time  he  committed  the  act  he  was  not  conscious  of  right  or 
wrong,  or  was  under  some  delusion  which  made  him  regard  the  act 
as  right. 

This  dictum,  it  will  be  observed,  takes  no  account  of  the  question 
of  defective  control,  an  omission  which  was  pointed  out  in  the 
exhaustive  treatise  of  Sir  Fitzjames  Stephen.  According  to  this 
eminent  jurist,  "  No  act  is  a  crime  if  the  person  who  does  it  is,  at  the 
time  when  it  is  done,  prevented  from  controlling  his  own  conduct, 
unless  the  absence  of  the  power  of  control  has  been  produced  by 
his  own  default."  I  do  not  propose  to  enter  into  any  discussion, 
regarding  the  diminution  of  the  will  in  ordinary  persons  or  even  in 
insanity;  but  I  am  quite  certain  that  in  persons  suffering  from, 
amentia  a  diminished  power  of  control  is  so  commonly  present,. 


The  Criminal   Responsibility  of  Aments      339 

and  such  an  essential  part  of  their  mental  condition,  that  a  grave 
injustice  may  be  done  if  this  be  not  taken  into  account.  Theremay 
be  non-defective  persons  who,  whilst  fully  appreciating  the  nature 
and  consequences  of  certain  criminal  acts,  are  yet  incapable  of 
refraining  from  committing  them,  and  such  cases  are  described 
as  impulsive  insanity.  But  it  cannot  be  doubted  that  there  are 
aments  who  suffer  from  a  delinite  defect  of  control  which  leads  them 
to  commit  criminal  acts.  I  would  therefore  say  that,  whilst  the 
mentally  deficient  person  is  not  necessarily  irresponsible  for  any 
crime  he  may  commit,  he  should  certainly  be  held  unaccountable 
when  he  commits  an  act  (i)  of  which  he  does  not  understand  the 
nature  or  that  it  is  contrary  to  law;  (2)  which  is  the  result  of  an 
impulse  he  was  unable  to  control;  (3)  which  is  the  natural  result  of  a 
delusion  of  which  he  is  shown  to  be  the  subject. 

With  regard  to  these  particular  qualifying  conditions  a  few  words 
may  be  said,  (i)  Want  of  knowledge  as  to  the  nature  or  illegality 
of  the  act  would  usually  be  capable  of  ready  demonstration  in  the 
case  of  idiots  and  imbeciles ;  but  even  in  the  milder  grades  defective 
intelligence  or  education  might  still  result  in  ignorance  as  to  how 
wrong  the  act  was  or  that  it  was  forbidden  by  law.  As  was  ably 
pointed  out  by  Sir  Fitz James  Stephen:  "  Knowledge  has  its  degrees 
like  everything  else,  and  implies  something  more  real  and  more 
closely  connected  with  conduct  than  the  half  knowledge  retained 
in  dreams."  As  an  instance  this  author  quotes  the  extreme  case 
of  the  idiot  who  cut  off  the  head  of  a  man  whom  he  found  asleep, 
remarking  that  it  would  be  great  fun  to  see  him  look  for  it  when  he 
woke;  and  he  adds:  "  Nothing  is  more  probable  than  that  the  idiot 
would  know  that  people  in  authority  would  not  approve  of  this, 
that  it  was  wrong  in  the  sense  in  which  it  is  wrong  in  a  child  not  to 
learn  its  lesson,  and  he  obviously  knew  that  it  was  a  mischievous 
trick."  And  it  cannot  be  doubted  that  the  same  kind  of  incom- 
plete knowledge  as  to  how  wrong  an  act  is  exists  in  the  case  of  many 
persons  suffering  from  a  mild  degree  of  mental  deficiency.  The 
high-grade  ament  at  Earlswood  Asylum,  who  has  been  mentioned 
as  attempting  the  destruction  of  an  official  who  had  displeased  him, . 
undoubtedly  knew  that  in  so  doing  he  was  doing  what  was  wrong, 
but  I  do  not  for  one  moment  think  that  he  appreciated  how  wrong 
his  act  was,  or  that,  had  it  succeeded,  he  could  justly  have  been 
held  fully  accountable  for  it.  Dr.  Mercier,*  commenting  on  this 
*  C.  Mercier,  "  Criminal  Responsibility,"  1905. 


340     Moral  Deficiency  and  Criminal  Aments 

■question  in  his  recent  philosophical  treatise,  says:  "  It  is  a  truth 
on  which  I  have  insisted  in  season  and  out  of  season  for  many- 
years,  that  a  man  may  know  that  his  act  is  wrong  without  knowing 
how  wrong  it  is."  This  defective  appreciation  of  the  wrongness  of 
an  act  is  the  distinguishing  feature  of  those  aments  lacking  in  moral 
sense. 

(2)  Pronounced  defect  of  control  in  aments  is  usually  clearly 
evident  from  infancy,  although  in  some  cases  it  may  not  attract 
attention  until  puberty.  It  is  one  of  the  chief  characteristics  of 
the  "  facile  "  and  "  impulsive  "  types  of  amentia,  and  of  some  of 
the  epileptics.  It  may  also  be  a  prominent  feature  in  some  of  those 
persons  we  have  described  as  the  "  morally  perverse  "  or  "  habitual 
criminal  "  type,  who  repeatedly  (and  often  openly)  commit  offences 
absolutely  undeterred  by  punishment. 

I  am  inclined  to  think  that  in  some  of  the  milder  cases  of  this 
kind  improvement  may  take  place  under  suitable  training,  and  that 
some  degree  of  control  may  be  developed;  but  pronounced  cases 
are  practically  hopeless,  and  although  it  may  be  extremely  difficult 
in  some  of  them  to  detect  any  intellectual  deficiency,  the  commission 
of  such  senseless  depredations  in  spite  of  punishment  clearly  points 
to  the  presence  of  a  disorder  of  mind.  On  the  other  hand,  there 
can  be  no  doubt  that  "  moral  deficiency  "  and  "  defective  will," 
or,  as  they  are  sometimes  more  euphemistically  described,  "  klepto- 
mania," are  often  put  forward  as  a  defence  when  the  individual  is 
fuUy  accountable  for  his  actions.  Personally  I  should  be  very  loath 
to  admit  defective  will-power  as  an  excuse  for  a  criminal  offence 
unless  the  accused  were  of  one  of  the  types  which  have  been  de- 
scribed, or  there  were  evidence  of  the  previous  commission  of  im- 
pulsive acts. 

(3)  The  commission  of  criminal  acts  in  consequence  of  delitsions 
practically  only  occurs  in  the  case  of  aments  who  are  also  insane. 
These  will  be  described  in  the  following  chapter,  but  here  it  may 
be  stated  that,  although  the  combination  of  insanity  and  mental 
deficiency  would  raise  a  strong  presumption  as  to  the  irresponsi- 
bility of  the  individual  so  affected,  he  could  only  justly  and  logically 
be  held  unaccountable  for  the  commission  of  a  criminal  act  when  it 
was  clearly  shown  that  his  delusion  or  mental  disease  did,  in  fact, 
prevent  him  from  knowing  the  nature  and  quality  of  the  act  at  the 
time  it  was  done,  or  from  controlling  his  own  conduct,  or  caused  him 
to  think  that  the  act  was  right.     For,  as  Mr.  Justice  Stephen  said: 


The  Criminal  Responsibility  of  Aments     341 

"  An  act  may  be  a  crime  although  the  mind  of  the  person  who  does 
it  is  affected  by  disease,  if  such  disease  does  not,  in  fact,  produce 
upon  his  mind  one  or  other  of  the  effects  above  mentioned  in  refer- 
ence to  that  act." 

It  is  thus  seen  that,  although  an  inquiry  into  the  criminal  re- 
sponsibility of  a  person  must,  of  necessity,  take  into  account  the 
state  of  that  person's  mind,  yet  the  question  is  not  in  reality  a 
medical,  but  a  legal  one.  It  is  the  duty  of  the  physician  to  place 
before  the  court  full  and  impartial  evidence  regarding  the  presence 
or  absence  of  such  mental  disease,  disorder,  or  deficiency  as  would 
influence  conduct ;  but  it  is  the  duty  of  the  judge  and  jury  to  decide 
whether  this  defect  or  disease  has  so  influenced  conduct  as  to  render 
the  accused  partially  or  wholly  irresponsible  for  his  act. 

In  defining  the  "  conditions  of  responsibility,"  Dr.  Mercier  arrives 
at  the  conclusion  that  "  to  incur  responsibility  by  a  harmful  act, 
the  actor  must  will  the  act;  intend  the  harm;  desire  primarily  his 
own  gratification.  Furthermore,  the  act  must  be  unprovoked  {i.e., 
without  adequate  provocation),  and  the  actor  must  know  and  appre- 
ciate the  circumstances  in  which  the  act  is  done." 

With  regard  to  civil  incapacity,  an  idiot  has  no  civil  rights, 
while  a  person  suffering  from  feeble-mindedness  can  be  adjudged 
incapable  of  managing  his  affairs  by  proceedings  in  Chancery.  In 
such  a  case  trustees  of  the  estate  might  be  appointed  without 
depriving  the  person  of  his  liberty;  in  other  words,  he  might  be  de- 
clared incapable  of  managing  his  affairs,  but  capable  of  managing 
himself.  .  Under  the  Mental  Deficiency  Act  of  1913,  the  administra- 
tion of  the  estate  of  a  defective  person  placed  in  an  institution  or 
under  guardianship  is  subject  to  similar  provisions  as  in  the  case  of 
a  lunatic  lawfully  detained  but  not  found  so  by  inquisition. 

An  idiot  is  inadmissible  as  a  witness,  but  in  the  case  of  an  imbecile 
or  feeble-minded  person  it  is  for  the  Judge  to  examine  and  ascertain 
whether  he  is  of  competent  understanding  to  give  evidence,  and  is 
aware  of  the  nature  and  obligation  of  an  oath;  if  satisfied  that  he  is, 
the  Judge  will  probably  allow  him  to  be  sworn  and  examined. 


CHAPTER  XVI 

INSANE    AMENTS 

In  the  literal  sense  of  the  word  "  insanity,"  all  aments  may  be 
looked  upon,  and  are  often  described,  as  "  congenitally  insane." 
But  nowadays  there  is  a  tendency  to  restrict  the  term  to  those  cases 
in  which  there  is  a  perversion  of  the  ego,  and  it  is  in  this  sense  that 
it  is  here  used.  Sir  George  Savage  says  a  man  must  be  considered 
as  sane  or  insane  in  relation  to  himself,  and  although  such  a  definition 
would  render  "  congenital  "  insanity  an  impossibility,  the  variations 
of  mental  function  and  capacity  in  the  mentally  deficient  are  so 
great  that,  from  the  standpoint  of  amentia,  there  is  much  to  be  said 
in  favour  of  using  the  ego  rather  than  the  "  normal  "  or  "  mean 
average  "  as  a  standard  of  reference. 

A  large  number  of  aments  react  to  their  environment  in  a  per- 
fectly consistent,  uniform,  and,  as  far  as  their  mental  capacity  will 
admit,  normal  manner,  and  such  may  be  considered  sane,  albeit 
defective.  On  the  other  hand,  a  certain  number  are  characterized 
by  lapses  from  their  ordinary  mental  state  of  such  intensity  that, 
for  the  time  being,  they  may  rightly  be  termed  insane;  it  is  with 
these  latter  that  this  chapter  deals. 

The  causes  of  insanity  are  twofold,  namely — predisposing  and 
determining.  Those  which  actually  determine  insanity  are  many 
and  varied,  ranging  from  a  slight  alteration  of  the  general  bodily 
health  and  condition  to  a  sudden  strain  or  prolonged  mental  or 
nervous  stress.  As  Dr.  Mercier  says,  however,  "  a  jerry-built  villa 
is  liable  to  be  blown  down  by  a  storm  of  wind,  but  nothing  short  of 
an  earthquake  will  destroy  a  well-constructed  mansion."  And  in 
the  great  majority  of  cases  of  insanity  there  is  a  predisposing  cause 
— namely,  an  instability  of  nervous  tissue.  This  instability  may  be 
congenital  or  acquired,  generally  the  former,  and,  in  view  of  the 
defective  structure  which  is  the  essential  basis  of  amentia,  one 

342 


Insane  Aments 


343 


would  expect  that  in  many  of  these  persons  there  would  be  a 
decided  nervous  instability  and  imperfect  capacity  of  resist- 
ance with  consequent  proneness  to  insanity;  this  is  found  to  be 
the  case. 

It  is  probable  that  the  actual  number  of  aments  who  are  thus 
predisposed  to  insanity  is  incapable  of  determination,  just  as  it  is 
impossible  to  calculate  the  proportion  of  potential  lunatics  in  the 
non-defective  population;  but  an  approximate  estimate  of  the 
number  of  the  feeble-minded  grade  of  aments  who  are  actually 
insane  can  be  made,  and  a  comparison  of  this  with  the  number  of 
the  ordinary  insane  will  give  an  idea  of  the  relative  predisposition 
in  the  two  classes. 

From  information  which  has  been  very  courteously  placed  at  my 
disposal  by  some  asylum  physicians,  as  well  as  from  my  own  observa- 
tions in  the  as3dums  of  the  London  County  Council  and  elsewhere, 
I  am  of  opinion  that  at  least  5  per  cent,  of  the  inmates  of  the  county 
and  borough  asylums  of  this  country  are  feeble-minded  insane  ;  we 
may  therefore  estimate  the  number  of  feeble-minded  certified 
lunatics  as  approximately  4,450,  or  about  8  per  cent,  of  the  total 
feeble-minded  of  the  country  (54,114). 

The  proportion  of  ordinary  or  non-defective  insane  to  the  total 
population  is  only  about  0*3  per  cent.,  from  which  it  appears  that 
the  predisposition  to  insanity  in  the  feeble-minded  is  twenty-six 
times  that  of  the  ordinary  population.  There  are,  of  course,  many 
of  the  non-defective  insane  who  are  not  certified,  but  so  there  are 
of  the  mentally  deficient  insane,  and  I  think  that  these  figures  ex- 
press the  relative  predisposition  to  insanity  which  exists  in  the  two 
classes  with  tolerable  accuracy.,  On  the  whole  I  believe  we  may 
say  that  quite  10  per  cent,  of  the  feeble-minded  have  a  definite 
insane  predisposition.  With  regard  to  this  tendency  in  imbeciles 
and  idiots,  I  am  unable  to  give  any  figures,  but  my  impression  is 
that,  although  it  is  considerably  less  than  in  the  merely  feeble- 
minded, it  is  still  much  greater  than  in  the  ordinary  population. 

There  is  no  doubt  that  a  considerable  number  of  the  non-defective 
insane  manifest  signs  of  a  diminished  power  of  will  or  other  failing 
from  a  very  early  age,  and  some  writers  would  go  so  far  as  to  include 
these  with  the  aments  proper.*  It  cannot  be  denied  that  there  is 
much  to  be  said  for  such  a  view,  for  these  persons  often  present  a 
physiognomy,    and   also   stigmata   of   degeneracy,    identical   with 

*  See  Bolton,  "  Amentia  and  Dementia,"  Journal  of  Mental  Science,  1907. 


344  Insane  Aments 

those  existing  in  the  mentally  defective.  I  doubt,  however,  whether 
these  should  really  be  classed  as  aments,  although  they  are  un- 
doubtedly on  the  borderland  between  this  condition  and  insanity, 
between  a  brain  which  is  the  seat  of  an  actual  arrest  of  anatomical 
structure  and  one  which  is  merely  unstable  and  of  defective  physio- 
logical potentiality.  They  serve  to  show  that,  just  as  the  three 
grades  of  amentia  merge  into  one  another,  so  in  turn  do  the  mildest 
members  of  the  aments  stand  in  extremely  close  relationship  to  the 
insane — that  idiocy  is,  indeed,  the  culmination  of  the  neuropathic 
diathesis.  In  this  place,  however,  I  shall  use  the  term  "  amentia  " 
in  the  manner  in  which  it  has  all  along  been  used,  and  shall  only 
refer  to  those  persons  who  show  definite  intellectual  deficiency. 

In  a  certain  number  of  these  aments  who  become  insane  there  are 
determining  factors,  just  as  in  the  ordinary  lunatics;  but,  on  the 
whole,  these  factors  are  much  less  in  evidence,  and  as  we  proceed 
down  the  scale  of  mental  deficiency  they  become  still  less  and  less 
frequent.  In  the  imbeciles  an  attack  of  insanity  may  suddenly 
appear  without  any  apparent  determining  cause  whatever,  and  the 
sudden  and  violent  storms  of  the  idiot,  which  must  be  looked  upon 
as  of  precisely  the  same  nature  as  true  insanity,  are  similarly  un- 
related to  any  obvious  cause.  During  these  attacks  the  child  or 
youth  will  rush  about,  making  hideous  noises,  overturning  or 
smashing  everything  in  his  way,  animate  as  well  as  inanimate,  and 
often  dashing  himself  with  great  violence  against  walls,  doors,  and 
pieces  of  furniture  which  he  cannot  displace.  Such  attacks  are 
liable  to  recur  with  more  or  less  constant  regularity,  although  each 
is  of  comparatively  short  duration.  The  extreme  mental  instability 
present  in  these  persons  must  be  considered  as  of  itself  sufficient 
to  determine  the  attack:  the  "  jerry-built  villa  "  topples  over,  not 
even  by  reason  of  any  storm  of  wind,  but  solely  because  of  its  own 
unstable  equilibrium. 

In  those  aments  who  develop  insanity  this  instability  is  usually 
present  and  recognizable  from  childhood.  As  a  boy  or  girl  the 
patient  has  been  subject  to  fits  of  irritability,  moroseness,  or  bad 
temper,  often  accompanied  by  acts  of  violence,  which  have  been  a 
cause  not  only  of  sorrow,  but  of  anxiety,  to  friends  and  relations;  and 
although  these  conditions  can  hardly  be  termed  insanity,  they  are 
the  shadows  of  the  coming  event,  being  evidence  of  that  special 
predisposition  which  will  almost  inevitably,  sooner  or  later,  ter- 
minate in  insanity.     It  is  possible  that,  could  the  \^outh  and  adoles" 


Insane  Aments  345 

cence  of  a  feeble-minded  person  of  this  class  be  passed  in  a  perfectly 
orderly  and  routine  manner,  away  from  the  bustle  of  the  outside 
world,  the  attack  might  be  long  deferred,  or  even  prevented.  In 
the  majority  of  cases,  however,  the  first  attack  makes  its  appearance 
between  the  periods  of  puberty  and  adolescence,  and  in  some  cases 
even  much  earlier  than  this. 

One  of  the  most  frequent  exciting  causes  in  the  mild  aments  is 
alcohol,  to  the  action  of  which  the  mentally  defective,  and,  indeed, 
neuropaths  generally,  seem  to  be  peculiarly  susceptible  and  par- 
ticularly intolerant.  A  severe  fright  may  likewise  precipitate  an 
attack  of  insanity  in  one  of  these  persons.  I  remember  a  mentally 
defective  child  who,  for  some  breach  of  school  discipline,  was  shut 
up  by  the  teacher  in  a  small  dark  room,  little  better  than  a  cup- 
board. When  taken  out  he  was  silent,  and  apparently  dazed. 
The  teacher  said  he  was  sulky,  but  he  continued  moody  and  de- 
pressed, and  a  few  days  afterwards  passed  into  a  state  of  profound 
melancholia  which  necessitated  his  removal  to  an  asylum.  Religious 
or  other  forms  of  excitement  may  also  act  as  determining  causes. 
One  small  boy  of  twelve  years  became  acutely  maniacal  as  the  result 
of  the  popular  excitement  attending  the  relief  of  Mafeking.  Another 
mentally  defective  youth  in  the  employ  of  an  Evangelical  clergyman 
was  so  worried  about  his  soul  by  this  zealous  but  indiscreet  gentle- 
man that  he  attempted  suicide.  Another  feeble-minded  young 
man  became  insane  in  consequence  of  the  repeated  theatre-going 
and  sight-seeing  provided  by  his  relations  with  the  idea  of  amusing 
him.  In  fact,  almost  any  trifling  occurrence,  which  would  have 
no  effect  upon  the  mind  of  a  healthy  person,  seems  to  be  enough 
to  upset  the  equilibrium  of  these  mentally  unstable  defectives, 
and  often  merely  the  physiological  changes  attending  puberty  or 
adolescence  are  sufficient. 

I  have  already  remarked  that  insanity  is  commoner  in  the  milder 
than  in  the  more  severe  grades  of  amentia,  and  in  the  latter  it  also 
tends  to  be  of  a  somewhat  different  type  to  that  in  the  feeble- 
minded, being  usually  an  emotional  storm  of  comparatively  short 
duration.  The  insanity  of  the  feeble-minded  and  high-grade 
imbeciles  does  not,  on  the  whole,  differ  from  that  occurring  in 
ordinary  persons,  and  to  give  some  idea  of  the  relative  frequencj^ 
of  the  different  clinical  types,  I  may  state  that  in  62  of  these  cases 
which  I  had  under  my  observation  for  a  considerable  period,  mania 
was  present  in  32,  melancJiolia  in  16,  alternating  mania  and  melan- 


34^  Insane  Aments 

choUa  in  6,  stupor  in  i,  delusional  insanity  in  i,  and  juvenile  general 
paralysis  in  6.  I  doubt  whether  the  relative  incidence  of  juvenile 
general  paralysis  is  really  so  great  as  would  appear  from  these 
figures;  since  it  is  probable  that  the  helpless,  demented  condition 
of  these  persons  leads  to  the  committal  of  an  undue  proportion  of 
them  to  asylum  care. 

We  may  now  briefly  refer  to  the  chief  clinical  types  of  insanity 
met  with  in  the  mentally  defective. 

Mania. — The  attacks  as  a  rule  present  the  ordinary  characteristics 
of  acute  mania,  the  patients  gesticulating,  shouting,  singing,  and 
rushing  about  for  days  together  without  cessation.  Sometimes 
they  are  exceedingly  violent,  using  abominable  language,  and 
smashing  everything  within  reach,  so  that  confinement  to  the 
padded  room  is  necessary.  One  girl  of  fourteen  years  attacked  her 
brothers  and  sister  with  a  poker  and  table-knives;  whilst  another, 
aged  sixteen,  stabbed  her  grandmother  and  attempted  to  set  fire  to 
the  house.  One  of  these  patients,  who  was  recovering,  accounted 
for  his  actions  by  saying  that  he  "  got  some  thought  on  his  mind, 
which  he  tried  to  get  off  and  couldn't;  this  caused  the  blood  to 
rush  to  his  head,  and  sent  it  rushing  down  his  arms  and  legs."  I 
am  of  opinion  that  a  certain  proportion  of  feeble-minded  criminals 
are  of  this  type,  and  that  their  offences  are  often  committed  whilst 
they  are  actually  insane.  In  many  cases  well-marked  aural  or 
visual  hallucinations  occur;  whilst  a  majority  of  them  suffer  from 
delusions,  chiefly  relating  to  the  identity  of  other  patients  or  of 
those  about  them.     The  following  are  illustrative  cases: 

Charles  H.  C ,  a  feeble-minded  youth  with  several  well- 
marked  stigmata  of  degeneracy;  said  to  have  always  been  very 
excitable;  no  regular  employment.  Admitted  to  the  asylum,  aged 
sixteen,  with  acute  mania  of  three  weeks'  duration.  He  had 
suddenly  become  noisy  and  sleepless,  throwing  himself  into  strange 
attitudes,  utterly  irrational  in  his  conversation,  shouting  out  "  God 
save  the  Queen,"  and  asking  to  be  allowed  to  fight  the  Boeis. 
Alternating  with  this  he  was  tearful  and  anxious,  with  delusions  of 
being  constantly  followed  by  policemen,  and  by  boys  who  called 
"  Thief  !"  after  him.  He  was  in  a  state  of  restless  agitation,  begging 
for  the  door  to  be  kept  locked.  For  a  week  after  admission  to  the 
asylum  he  remained  in  this  excited  condition  day  and  night,  and  it 
was  quite  impossible  to  control  him.  He  was  terrified  of  the  other 
patients,  thinking  they  were  all  trying  to  strangle  him.     After  a 


Plate  XXVI. 


Tiy/acc />as-c'  346.] 


Insane  Aments  347 

week  he  gradually  became  quieter,  and  at  the  end  of  two  months 
had  become  so  quiet  and  well-behaved  that  he  was  discharged. 

A.  C,  male,  aged  twent3^-five  years.  Has  always  been  back- 
ward, and  never  learnt  to  read  or  write.  After  leaving  school 
earned  a  few  shillings  weekly  by  doing  odd  jobs,  but  had  no  regular 
employment.  Apt  to  behave  queerly  at  times  from  early  boyhood, 
and  on  several  occasions  disappeared  from  home  for  two  or  three 
days.  At  the  age  of  twenty-four  began  to  attend  music-halls 
frequently,  and  shortly  afterwards  became  exceedingly  strange  in 
his  manner;  he  refused  to  do  any  work,  and  spent  most  of  his  time 
standing  at  the  open  window  talking  to  people  he  imagined  he  saw. 
Much  of  his  conversation  was  about  one  "  Flo  Arnold,"  whom  he 
wished  to  marry,  for  which  purpose  he  said  he  had  taken  £2  out  of 
the  bank.  He  gradually  became  quarrelsome,  and  finally  violent 
and  acutely  maniacal,  and  had  to  be  sent  to  the  asylum.  This 
condition  of  mania,  with  delusions  and  aural  hallucinations,  lasted 
for  tv/o  months,  after  which  he  became  quieter.  He  has  now  been 
in  the  asylum  for  nearly  two  years.  He  is  subject  from  time  to 
time  to  sudden  outbursts  of  maniacal  excitement,  lasting  from  a  few 
hours  to  several  days ;  these  are  probably  due  to  delusions,  although 
none  can  be  ascertained.  He  shows  indications  of  the  onset  of 
dementia, 

A.  F.,  female.  "Always  simple  from  quite  a  child."  Left 
school  aged  twelve,  being  only  in  second  standard;  afterwards 
in  a  training  home;  very  bad-tempered  and  addicted  to  smashing 
windows;  sent  home  after  three  years,  as  they  found  they  could 
do  nothing  with  her.  At  the  age  of  sixteen  she  became  so  violent 
that  she  had  to  be  removed  to  the  asylum,  having  previously  hurled 
a  cooper's  hammer  at  a  man  and  thrown  a  heavy  padlock  at  a 
woman.  She  remained  in  a  condition  of  maniacal  excitement  for 
three  months,  with  an  occasional  short  interval  of  comparative 
calm.  During  one  of  these  I  asked  her  why  she  behaved  so  vio- 
lently; she  said  something  came  over  her  and  she  felt  she  "  must 
do  it."  In  the  next  three  months  she  became  much  quieter,  and 
for  the  following  five  months  she  remained  silent  and  gloomy, 
refusing  to  have  anything  to  do  with  the  other  patients;  then  she 
relapsed  into  a  state  of  restless  excitement  lasting  for  a  month, 
followed  by  another  period  of  depression.  She  is  now  nineteen 
years  of  age,  having  been  in  the  asylum  three  years.  She  is  at 
times  fairly  quiet  and  does  a  little  ward  work,  but  is  very  untrust. 


348  Insane  Aments  . 

worthy,  and  liable  to  sudden  outbursts  of  maniacal  excitement  with 
destructiveness ;  she  is  highly  emotional  and  unstable,  bursting  into> 
fits  of  tears  or  laughter  without  any  apparent  cause.  There  are  no- 
indications  of  dementia. 

R.  D.,  female.  Very  backward  at  school;  left  aged  thirteen 
and  went  to  service,  but  was  so  liable  to  what  her  mother  calls- 
"  fits  of  temper  "  that  she  could  not  keep  any  situation  more  than 
a  few  months;  altogether  she  had  fourteen  situations  in  less  than 
three  years.  At  the  age  of  sixteen  she  became  so  violent  that  she 
was  sent  to  the  asylum.  On  admission  she  was  in  a  state  of  acute 
mania,  screaming,  shouting,  singing,  and  resisting  all  attempts  to- 
keep  her  in  bed;  she  also  threatened  to  cut  her  throat.  This  con- 
dition lasted  for  a  few  days  after  admission ;  she  then  became  quieter, 
and  by  the  end  of  a  fortnight  was  doing  some  work  in  the  wards. 
Within  a  month  she  had  a  relapse  exactly  similar  to  the  first  attack. 
She  is  now  twenty  years  of  age,  and  has  been  in  the  asylum  four 
years.  At  times  she  is  quiet,  well-behaved,  and  answers  questions 
readily  and  pleasantly;  it  is,  however,  quite  impossible  to  depend 
upon  her,  and  she  is  subject  from  time  to  time  to  sudden  outbreaks 
of  excitement,  in  which  she  becomes  most  abusive,  uses  the  foulest 
language,  and  violently  attacks  anyone  who  may  be  in  her  way. 
These  outbursts  last  for  three  or  four  days  and  nights;  as  a  rule 
they  seem  to  be  purely  emotional  storms,  but  in  some  of  them 
delusions  are  present,  generally  to  the  effect  that  the  medical  officers 
and  the  nurses  are  trying  to  cut  off  her  head  or  to  torture  her  in 
various  ways. 

E.  S.,  female.  Simple-minded  from  birth;  did  not  get  on  at 
school;  subsequently  kept  at  home  to  help  mother,  "  as  she  did  not 
seem  to  have  enough  sense  to  go  out  to  work  ";  was  at  times  very 
troublesome,  and  caused  much  annoyance  by  suddenly  rushing  into 
the  neighbours'  houses.  At  the  age  of  sixteen  became  so  restless 
and  excitable  that  they  could  do  nothing  with  her,  and  sent  her 
to  the  asylum.  The  medical  certificate  states  "  she  exhibits  undue 
mental  excitement,  talks,  sings,  shouts,  and  laughs  immoderately 
and  behaves  in  an  insane  manner ;  very  restless,  imagines  the  atten- 
dants to  be  her  former  school-teachers,  and  seems  altogether  too 
excited  to  control  herself  and  talk  sensibly."  This  acute  condition 
gradually  abated,  and  by  the  end  of  three  months  she  had  become 
quiet  and  able  to  do  work;  two  months  later  she  relapsed,  again 
becoming  excited,  noisy,  and  destructive  day  and  night,  in  which 


Plate  XXVII. 


To  face  page  34S.] 


Insane  Aments  349 

state  she  remained  for  three  weeks,  then  becoming  quiet  and  in- 
dustrious again.  She  has  now  been  in  the  asylum  seven  years, 
has  ceased  to  do  any  work,  and  is  subject  to  frequent  acute  outbreaks 
of  noisy  aggressiveness.  In  some  of  these  attacks  delusions  are 
present ;  thus,  a  short  time  ago  she  stated  that  she  had  given  birth 
to  a  child,  which  had  been  stolen  from  her  in  the  night.  She  is 
very  impulsive,  and  on  one  occasion,  seeing  a  pail  of  water  standing 
in  the  ward,  she  suddenly  plunged  her  head  into  it.  She  is  becoming 
very  untidy  in  her  dress  and  personal  appearance,  though  there  are 
as  yet  no  other  indications  of  dementia. 

C.  R.,  female  imbecile.  Never  passed  first  standard  at  school; 
subsequently  kept  at  home;  could  never  be  depended  upon;  and 
from  nine  years  of  age  has  been  at  times  very  violent  and  addicted 
to  using  disgusting  language.  She  had  to  be  sent  to  the  asylum 
at  the  age  of  fourteen,  and  on  admission  was  in  a  state  of  mania, 
chattering  to  herself  and  singing  or  shouting  the  whole  day.  iVt 
times  destructive  and  aggressive;  very  restless  at  night.  She  has 
now  been  in  the  asylum  for  six  months,  and  on  the  whole  there  is 
very  little  improvement.  She  is  occasionally  fairly  quiet  and 
rational,  but  as  a  rule  she  is  raging  up  and  down  the  wards  singing, 
shouting,  and  swearing  at  the  other  patients.  The  charge-nurse 
says  she  is  her  most  troublesome  patient. 

Melancholia. — Both  active  and  passive  varieties  of  melancholia 
occur  in  aments,  and  the  majority  of  cases  are  accompanied  by 
definite  delusions  or  hallucinations.  Refusal  of  food  is  common, 
and  threats  or  attempts  at  suicide  occur  in  a  considerable  number 
of  these  patients.  Active  melancholia  is  commonly  preceded  or 
accompanied  by  terrifying  delusions.  Thus,  one  young  girl  was 
frightened  by  seeing  a  fight  in  the  street;  she  became  timid  and 
anxious,  and  in  a  few  days  developed  pronounced  delusions  to  the 
effect  that  people  were  trying  to  kill  and  burn  her.  She  heard 
voices  threatening  her,  thought  that  her  food  was  poisoned,  and 
refused  to  eat  it,  and,  in  fact,  became  apprehensive  of  harm  from 
every  imaginable  quarter.  She  was  in  a  restless  state  of  tearful 
agitation,  constantly  wringing  her  hands,  and  muttering,  "  What 
are  they  going  to  do  to  me  ?"  Another  boj'  had  the  curious  delusion 
that  he  had  fallen  to  pieces  and  lost  some  of  his  parts.  The  passive 
form  of  melancholia  of  these  persons  seems  at  times  to  be  the  out- 
come of  a  morbid  consciousness  that  they  are  not  quite  as  other 
people.     They  feel  neglected,  or,  as  they  sometimes  say,   "  of  no 


350  Insane  Aments 

use."  The  rebuke  or  sharp  word  of  employer  or  parent  is  keenly 
felt,  and  they  acquire  a  habit  of  brooding  over  their  fancied  wrongs. 
It  is  very  common  to  hear  feeble-minded  persons  in  this  frame  of 
mind  complain  that  they  have  "  not  had  fair  play."  Pronounced 
delusions  of  persecution  soon  follow,  and  these  pass  into  a  state  of 
apathetic  melancholia.  If  they  can  be  got  to  converse  at  all,  their 
remarks  will  often  be  to  the  effect  that  they  are  "  tired  of  life  and 
want  to  die,"  and,  indeed,  attempts  at  suicide  are  by  no  means 
uncommon.  These  attempts  are  often  real  and  definite  efforts  to 
put  an  end  to  existence,  and  drowning  seems  to  be  the  method 
which  most  appeals  to  them.  Many  of  these  patients  become 
utterly  careless  of  personal  cleanliness,  refuse  to  work,  dress,  or 
take  food,  and  sometimes  resist  any  attempt  on  the  part  of  their 
attendants  to  see  to  these  matters  for  them. 

Stupor. — This,  apparently,  is  not  very  common  in  the  feeble- 
minded, but  I  have  seen  one  well-marked  case  which,  beginning  as 
passive  melancholia,  with  visual  hallucinations  and  refusal  of  food, 
gradually  developed  into  a  condition  of  complete  stupor — indeed, 
almost  catalepsy.  The  patient  was  a  mentally  defective  boy  of 
fifteen  years,  and  for  weeks  he  sat  in  one  place,  staring  vacantly  in 
front  of  him,  dribbling  from  his  mouth,  requiring  to  be  fed  with  a 
spoon,  and  absolutely  indifferent  to  the  calls  of  nature.  He  was 
discharged  cured  from  the  asylum  in  nine  months,  but  readmitted 
six  months  later  with  a  precisely  similar  attack.  This  in  turn 
slowly  passed  away  after  a  few  months,  to  be  followed  by  a  state 
of  extreme  fatuity,  the  youth  being  liable  to  sudden  outbursts  of 
laughter  or  crying  without  any  observable  cause  (see  Fig.  67). 
The  following  are  illustrative  cases  of  melancholia: 
C.  D.,  male.  He  could  never  learn  arithmetic  at  school,  as  the 
master  said  his  "  brain  was  too  weak."  Used  to  behave  very 
oddly  at  times.  After  leaving  school  was  employed  in  a  bootshop. 
At  the  age  of  sixteen  he  was  frightened  by  a  large  black  dog,  and 
shortly  afterwards  became  much  depressed,  gradually  passing  into 
a  condition  of  melancholia.  On  admission  to  asylum  he  was  found 
to  have  aural  and  visual  hallucinations  with  delusions.  He  thought 
he  was  surrounded  and  threatened  by  black  men;  he  said  that  he 
was  afraid  he  was  going  to  be  killed  in  the  China  War,  and  that  God 
told  him  to  kill  himself.  For  several  days  he  was  restless  and 
anxious,  afterwards  becoming  dull,  listless,  lethargic,  and  a  con- 
firmed masturbator;  he  would  occasionally  waken  out  of  this  stupor- 


Plate  XXVIII. 


-a  "-  e 

1     (L>    ^  <^ 


Toface:page  350.] 


Insane  Aments  351 

ose  condition  to  become  aggressive  and  violent.  Four  years  after 
admission  he  had  so  much  improved  that  he  was  discharged  to  his 
friends,  only  to  be  readmitted  six  weeks  later,  as  they  found  it 
impossible  to  manage  him.  He  is  now  twenty-two  years  of  age, 
and  is  still  in  the  asylum,  being  idle  and  as  a  rule  dull  and  de- 
pressed, and  constantly  muttering  to  himself;  occasionally  destruc- 
tive and  aggressive;  signs  of  dementia  are  apparent. 

T.  K.,  male.  Mental  deficiency  noticed  from  early  childhood; 
incapable  of  learning  at  school;  no  work  subsequently;  never 
earned  any  money.  Gave  much  trouble  to  his  parents,  being 
"  very  bad-tempered,"  and  frequently  wandering  away  from  home. 
At  sixteen  years  of  age  became  much  depressed,  and  attempted 
suicide  by  taking  carbolic  acid.  On  admission  into  asylum  was 
wretched  and  tearful,  saying  that  he  wanted  to  die,  and  there  was 
no  reason  why  he  should  live.  He  gradually  became  brighter  and 
even  cheerful,  and  a  month  after  admission  was  able  to  work  out  of 
doors;  the  improvement  continued,  and  he  was  discharged  in  four 
months.  Eight  months  later  he  was  readmitted,  having  been 
found  by  a  policeman  battering  his  head  against  some  iron  railings. 
On  the  way  to  the  station  he  said  that  he  would  kill  either  himself 
or  his  father,  the  latter  stating  that  he  had  been  violent  and  had 
attempted  to  cut  his  (the  father's)  throat.  He  was  profoundly 
depressed,  thought  he  heard  voices,  and  that  people  had  conspired 
to  kill  him.  At  the  present  time  he  has  been  in  the  asylum  four 
months.  He  is  still  depressed  and  solitary,  but  on  the  whole  de- 
cidedly brighter,  doing  a  little  work,  and  appears  to  have  lost  his 
delusions. 

Alternating  and  Recurrent  Insanity. — In  some  cases  the  insanity 
takes  the  form  of  alternating  attacks  of  mania  and  melancholia. 
In  these  patients,  however,  there  are  not  usually  intervening  periods 
of  complete  cessation,  as  in  the  folic  circulaire  of  French  authors. 
The  mania,  which  may  be  violent  and  acute,  lasts  for  a  time,  and 
is  then  replaced  by  a  state  of  melancholia  of  the  ordinary  variet}-, 
or  vice  versa,  and  so  the  process  continues.  Perhaps  such  cases 
should  rather  be  classed  as  recurrent  insanity,  and  they  usually 
terminate  in  dementia.  It  may  be  said  here  that  in  about  one- 
third  of  the  cases  coming  under  my  own  observation  there  was  no 
recovery  from  the  first  attack;  the  mania  or  melancholia  became 
lessened  in  its  intensity,  but  persisted  as  chronic  insanity,  grad- 
ually to  terminate  in  dementia.     In  about  two-thirds  of  the  cases. 


352  Insane  Aments 

however,  the  first  attack  gradually  and  completely  subsided  after 
a  period  varying  from  a  few  weeks  to  two  or  three  months ;  but  the 
improvement  was  only  temporary,  and,  as  far  as  my  experience 
goes,  there  is  scarcely  any  class  of  patient  in  whom  a  recurrence 
is  more  likely  to  take  place.  This  is  seldom  deferred  for  more 
than  a  year,  and  in  the  majority  of  the  cases  it  comes  on  within  a 
few  months  of  the  subsidence  of  the  original  attack.  The  second 
and  subsequent  attacks  are  usually  of  the  same  chnical  type  as  the 
first,  and  they  continue  to  occur  at  periods  varying  from  three  to 
twelve  months  for  many  years.  In  the  intervals  the  patient  is 
fairly  quiet,  and  may  do  a  certain  amount  of  useful  work,  although 
his  mental  deficiency  and  instability  prevent  any  regular  employ- 
ment. With  the  lapse  of  time,  however,  the  insane  attacks  tend  to 
recur  more  and  more  frequently,  and  the  patient  gradually  passes 
into  a  state  of  chronic  insanity,  which  is  only  terminated  by  the 
development  of  dementia. 

Epileptic  Insanity. — Many  feeble-minded  and  imbecile  epileptics 
are  exceedingly  irritable  and  liable  to  outbreaks  of  furious  passion, 
and  a  considerable  number  develop  insanity  just  the  same  as  do 
ordinary  epileptics.  There  are  no  special  features,  and  the  tendency 
is  usually  to  early  dementia. 

Delusional  Insanity. — It  is  of  the  utmost  importance  for  those 
who  have  dealings  with  the  feeble-minded  to  remember  that  many 
of  them  will  make  the  most  untruthful  statements  with  a  persistence 
and  an  amount  of  detail  which  may  excite  a  ready  credence  in  the 
unguarded.  Whether  such  statements  should  be  classed  as  delu- 
'sions  it  is  difficult  to  say.  Sometimes  I  think  the  person  does 
actually  believe  them  to  be  true,  that  he  is,  in  fact,  deluded;  but 
in  other  instances  they  are  simply  make-believe  flights  of  fancy; 
whilst  in  a  few  they  are  the  outcome  of  pure  \\ickedness.  But  if 
these  possibilities  be  not  borne  in  mind,  the  consequences  may  be 
very  serious.  I  have  known  feeble-minded  children  accuse  their 
companions  and  teachers  of  all  sorts  of  offences  without  the  slightest 
foundation.  I  have  known  a  feeble-minded  girl  accuse  a  medical 
examiner  of  rape,  and  only  recently  I  was  asked  by  the  police  to 
examine  a  feeble-minded  girl  of  sixteen  who  swore  most  positively 
that  her  own  father  had  been  constantly  in  the  habit  of  having 
sexual  intercourse  with  her.  It  was  subsequently  proved  that  the 
charge  was  absolutely  false.  Another  girl  of  this  type  caused 
grave  scandal  in  the  vihage  in  which  she  lived  by  circulating  the 


Plate  XXIX. 


^k 

^B 

(^ 

....  SI 

To  face  page  ■iS2.'\ 


Insane  Aments  353 

statement  that  she  was  constantly  in  the  habit  of  going  for  long, 
solitary  walks  with  the  vicar.  This,  again,  was  shown  to  be  without 
a  particle  of  truth.  Occurrences  like  this  are  common,  but  a  pure 
delusional  insanity,  in  which  the  delusions  remain  fixed  for  a  long 
period  and  do  seem  to  be  actually  believed  in,  is  not  so  common. 
The  following  is  a  fairly  typical  example : 

H.  M.,  a  feeble-minded  woman  of  thirty-three  years  of  age, 
but  small,  ill-developed,  and  not  looking  more  than  twenty- 
three  years.  Her  parents  say  that  she  never  seemed  bright  intel- 
lectually, and  since  she  left  boarding-school  at  the  age  of  nineteen 
she  has  been  at  home  helping  a  little  in  the  house  and  garden,  but 
taking  no  responsibility.  During  the  last  five  years  she  has  become 
enamoured  of  several  men  she  has  chanced  to  meet,  continually 
talking  about  them  and  trying  to  meet  them,  although  they  have 
apparently  been  quite  ignorant  of  her  feelings  and  have  certainly 
given  her  no  encouragement.  Twelve  months  ago  she  became 
infatuated  with  a  professional  man  [Mr.  C),  whom  she  had 
accidentally  met  at  a  friend's  house,  and  since  then  he  has  occupied 
all  her  thoughts.  She  writes  letters  to  him,  she  is  perpetually 
talking  about  him,  and  on  several  occasions  her  father  has  met  her 
slipping  out  of  the  house  at  night  to  go  and  see  him,  as  she  said. 
Her  behaviour  caused  such  trouble  to  her  parents  that  she  was 
placed  in  the  house  of  a  medical  man  in  the  hope  that  change  of 
scene  would  lead  to  change  of  thoughts.  But  she  insisted  that 
Mr.  C.  had. followed  her;  she  said  that  he  was  walking  in  the 
garden  waiting  to  give  her  an  engagement  ring,  and  on  several 
occasions  she  said  that  he  had  been  in  her  room  talking  to  her, 
although  he  was  in  reality  a  hundred  miles  away.  When  she  was 
brought  to  see  me  six  months  later  she  still  had  the  same  delusion; 
she  insisted  that  Mr.  C.  had  come  up  in  the  same  train  with  her, 
that  she  saw  him  get  out  at  the  station,  and  that  at  the  present 
moment  he  was  waiting  for  her  in  the  street.  As  her  father  told  me 
that  on  several  nights  she  had  got  out  of  bed  and  had  been  found 
walking  in  the  garden,  that  she  was  constantly  slipping  out  of  the 
house,  and  that  they  were  finding  it  exceedingly  difficult  to  keep 
her  under  observation,  I  advised  that  she  should  be  certified  and 
placed  in  a  private  asylum.  This  was  done,  but  at  the  present 
time,  six  months  later,  her  condition  is  unchanged,  and  she  insists 
that  Mr.  C.  is  in  the  grounds  or  the  next  room,  asking  to  see 
her,  and  she  is  very  angry  with  the  nurse  for  not  allowing  her  to  go 

23 


354 


Insane  Aments 


to  him.  So  far  as  can  be  ascertained,  she  has  never  spoken  to  or 
even  seen  the  object  of  her  affections  since  their  first  meeting. 

General  Paralysis. — Aments  may  suffer  from  general  paralysis  of 
either  the  adolescent  (juvenile)  or  ordinary  variety;  but  the  latter 
is  relatively  rare.  The  symptoms  usually  make  their  first  appear- 
ance between  the  ages  of  fourteen  and  nineteen  years,  and  consist 
of  a  well-marked  mental  change.  The  patient  becomes  either 
gloomy,  depressed,  and  apathetic,  or  noisy,  excited,  and  maniacal. 
Very  often  delusions  of  identity  or  of  persecution  are  present,  and 
there  may  be  attempts  at  suicide.  In  some  instances  the  mental 
disturbance  takes  the  form  of  violent  emotional  storms  of  alternate 
excitement  and  depression.  This  condition  persists  with  exacerba- 
tions and  remissions  for  from  one  to  two  years,  by  which  time  the 
patient  usually  shows  definite  indications  of  mental  and  physical 
enfeeblement,  the  course  thence  to  the  end,  a  few  years  later,  being 
similar  to  that  in  ordinary  patients.  In  the  cases  which  have  come 
under  my  own  notice  there  has  always  been  a  history  or  signs  indi- 
cative of  congenital  syphilis,  and  I  think  that  general  paralysis  is 
the  usual  (but  not  invariable)  termination  when  this  is  present  in 
the  mentally  defective. 

The  foUowing  cases  illustrate  the  chief  features  of  this  complica- 
tion of  amentia: 

M.  p.,  female,  the  sixth  of  a  family  of  ten.  The  fifth  died  of 
"  water  on  the  brain  "  in  infancy,  and  the  seventh  and  eighth  were 
miscarriages.  The  remainder  are  said  to  be  "  all  right."  There  is 
phthisis  on  the  mother's  side,  but  no  insanity  discoverable.  The 
patient  was  decidedly  backward  at  school;  afterwards  she  stayed 
at  home  to  help  her  mother,  as  she  did  not  seem  equal  to  taking  a 
place.  At  the  age  of  nineteen  years  she  began  to  get  mischievous 
and  destructive,  and  finally  became  so  troublesome  that  she  had 
to  be  sent  to  an  asylum.  On  admission  in  October,  1899,  she  was 
described  as  being  of  very  poor  intelligence,  wet  and  dirty  in  habits, 
noisy  day  and  night,  talking  incessantty  and  using  disgusting  lan- 
guage without  any  connexion  of  ideas.  Her  condition  was  such 
that  systematic  examination  was  impossible.  She  gradually  became 
somewhat  quieter,  and  when  seen  by  me,  nine  months  after  admis- 
sion, her  condition  was  as  follows:  A  lethargic,  almost  stuporose 
girl  who  spent  the  whole  day  sitting  in  a  chair,  indifferent  to  any- 
thing happening  round  her.  She  understood  what  was  said  to  her, 
but  was  unable  to  carry  on  conversation  or  to  answer  simple  ques- 


Insane  Aments  355 

tions  properl}^.  Speech  slurred  and  tremulous.  She  attempted  to 
write  at  my  request,  but  her  hand  was  so  shaky  that  it  was 
impossible  to  do  so.  Knee-jerks  greatly  exaggerated;  extremities 
blue  and  cold.  No  paresis;  no  seizures.  Well-marked  signs  of 
rickets  and  congenital  syphilis.  I  diagnosed  syphilitic  amentia, 
with  beginning  general  paralysis,  but  was  unable  to  see  the  patient 
again,  and  had  entirely  forgotten  about  her  until  going  through 
my  notes.  The  medical  superintendent  was  good  enough  to  supply 
me  with  the  subsequent  history,  from  which  it  appeared  that  un- 
mistakable signs  of  general  paralysis  were  noted  towards  the  end  of 
1901;  that  phthisis  was  observed  in  February,  1902;  and  that  she 
died  on  March  29  of  the  same  year.  Her  age  at  death  was  twenty- 
three  years,  and  the  cause,  as  ascertained  post-mortem,  was  general 
paralysis  and  phthisis. 

T.  C,  male.  Father  alcoholic  and  insane;  his  mother  and  all 
his  brothers  and  sisters  alcoholic.  The  patient  is  the  second  of  a 
family  of  eight;  the  first-born  died  aged  two  and  a  half  months, 
and  the  mother  was  told  by  the  doctor  that,  had  it  lived,  "  it  would 
have  been  blind  and  an  idiot."  The  fourth  child,  whom  I  have 
seen,  has  marks  of  congenital  syphilis.  The  patient  was  backward 
in  walking  and  talking;  his  mother  says  he  could  never  "  get  his 
words  out  properly."  He  went  to  school,  but  could  never  learn, 
and  the  schoolmaster  said  he  was  "  a  regular  fool."  He  subse- 
quently had  several  situations,  but  no  one  would  keep  him  very 
long.  At  fifteen  years  of  age  he  began  to  get  very  bad-tempered 
and  strange  in  his  manner;  he  had  attacks  of  screaming,  which 
lasted  for  hours;  and  ultimately,  at  seventeen  years,  was  sent  to 
an  asylum  with  acute  mania.  This  gradually  subsided,  revealing  a 
condition  of  mild  imbecility  with  beginning  dementia.  When  asked 
his  name  and  age,  he  would  plaintively  reply:  "  I  ain't  got  no  name  " 
and  "  I  ain't  got  no  age."  The  dementia  progressed  and  became 
extreme,  and  he  died,  aged  nineteen,  of  exhaustion  following  a  bout 
of  seizures. 

The  post-mortem  examination  revealed  a  simply  convoluted 
brain,  weighing  1,167  grammes,  and  having  the  characteristic 
appearances  of  general  paralysis.  The  microscope  showed  a  con- 
dition of  imperfect  cellular  development,  plus  subacute  degenera- 
tion, similar  to  that  occurring  in  general  paralysis. 

L.  B.,  female.  Was  admitted  into  the  asylum  at  the  age  of 
fifteen,  the  certificate  stating:  "  She  sits  apparently  dazed,  taking 


356  Insane  Aments 

no  interest  in  anything  that  is  going  on.  Threatened  to  kill  herself. 
Tears  her  clothing,  and  at  times  cries  and  stamps  her  feet."  The 
history  is  incomplete,  but  it  was  elicited  that  the  patient  had  been 
dull  and  of  defective  eyesight  since  birth;  that  her  mother  died, 
aged  forty-two,  of  general  paralysis;  and  that  her  father  was  alive, 
and  said  to  be  in  good  health.  Though  intellectually  dull,  she  was 
said  to  have  been  cheerful  until  the  last  six  months,  since  when  she 
had  become  stubborn  and  morose,  finally  helpless,  dirty  in  her 
habits,  and  quite  unable  to  look  after  herself. 

On  admission  the  pupils  were  dilated,  the  reaction  to  light  slug- 
gish, and  her  memory  for  time  and  events  much  impaired.  She 
was  gloomy  and  apathetic,  and  had  delusions,  such  as  that  ferocious 
dogs  were  coming  after  her.  There  was  left  external  strabismus, 
but  no  other  observable  paresis  and  no  convulsions.  The  knee- 
jerks  were  exaggerated.  Marks  of  congenital  syphilis  were  present. 
Cranial  circumference,  2if  inches.  She  was  considered  to  be  a 
case  of  syphilitic  amentia  with  superadded  dementia.  The  dementia 
steadily  increased,  and  the  patient  died  at  the  age  of  eighteen  years 
of  broncho-pneumonia. 

On  making  a  post-mortem  examination,  I  found  the  brain  to  be 
of  fair  size  (1,176  grammes),  but  somewhat  simply  convoluted.  The 
optic  nerves  were  exceedingly  small.  The  brain  and  membranes 
had  the  characteristic  naked-eye  appearances  of  general  paralysis. 
A  microscopical  examination  of  various  regions  of  the  cortex  cerebri 
revealed  a  marked  numerical  deficiency  of  the  cells;  many  of  them 
were  also  of  incomplete  development  and  irregular  arrangement. 
These  indications  of  imperfect  development  were  most  pronounced 
in  the  small  and  medium-sized  pyramidal  cells  of  the  frontal  lobes. 
In  addition,  there  was  a  considerable  amount  of  chronic  and  sub- 
acute degeneration,  with  proliferation  of  neuroglia  identical  with 
that  occurring  in  general  paralysis. 

Daisy  K ,  female,  twenty-two  years.     Always  seemed  dull 

mentally,  left  school  aged  fifteen  years,  and  has  been  at  home  since, 
as  she  never  seemed  sharp  enough  to  earn  her  living.  For  the  last 
twelve  months  has  been  subject  to  what  mother  calls  "  hysterical 
fits,"  during  which  "  she  screams,  throws  herself  about,  and  does 
not  seem  able  to  control  herself  at  all."  For  the  last  nine  months 
her  memory  has  been  failing,  and  she  has  become  less  capable  of 
doing  little  jobs  about  the  house;  she  has  also  been  getting  much 
thinner,  and  there  has  been  a  marked  alteration  in  her  manner  of 


Insane  Aments  357 

walking — "  She  seems  to  be  losing  power  in  her  legs."  During  the 
last  six  months  her  mother  has  noticed  trembling  of  hands  and 
mouth,  she  has  become  slovenly  in  her  feeding,  and  on  several 
occasions  has  wetted  herself.  She  got  rapidly  worse,  and  when 
brought  to  me  there  was  very  considerable  wasting;  the  nose, 
cheeks,  and  extremities  were  livid  and  cold ;  there  was  much  tremor 
of  hands,  tongue,  and  mouth;  her  handwriting  was  so  shaky  as  to 
be  illegible;  the  pupils  were  unequal  and  did  not  react  to  light; 
interstitial  keratitis  was  present  and  well-marked  syphilitic  teeth; 
the  knee-jerks  could  not  be  obtained;  the  hand-grasps  were  very 
feeble,  and  the  walk  staccato  in  character.  Mentally  there  was 
considerable  loss  of  memory  and  intellectual  impairment.  To 
many  questions  she  made  no  response,  and  to  others  only  after  a 
long  silence.  She  knew  where  she  was,  but  had  no  knowledge  of 
the  day  or  year.  She  was  at  times  silent  and  depressed,  but  at 
others  noisy  and  excited;  she  refused  food,  resisted  being  washed 
and  dressed,  and  was  constantly  wet  and  dirty.  She  was  removed 
to  the  asylum,  where  she  died  a  few  months  later  of  general  paralysis. 
With  regard  to  the  family  history,  the  father  had  contracted  syphilis 
several  years  before  marriage,  for  which  he  had  been  treated  for 
two  years.  He  is  alive  at  the  present  time,  aged  fifty-five  years, 
being  addicted  to  alcohol  and  having  twice  failed  in  business.  Both 
the  mother's  parents  died  of  apoplectic  strokes,  the  mother  herself 
being  alive,  aged  fifty-four  years. 

The  following  case  of  General  Paralysis  in  an  Adult  Ament  is 
recorded  "by  Dr.  Cappelletti:* 

The  patient,  a  female  imbecile  aged  fifty-four  years,  was  turned 
out  of  her  home  by  her  brother,  and  came  to  great  want;  she  was 
taken  into  the  asylum  in  a  maniacal  condition.  She  had  a  small, 
asymmetrical  skull,  tremor  of  tongue,  face,  and  extremities,  hesi- 
tating and  tremulous  speech,  wide,  unequal  pupils  which  only 
reacted  feebly  to  light  and  accommodation.  No  signs  of  sj/philis 
on  the  body.  Mental  condition  exalted,  with  grandiose  ideas. 
Death  occurred  after  two  years  in  consequence  of  apoplectiform 
attacks.  Post-mortem  examination  showed  thickening  of  the  dura 
and  pia,  with  adhesions  and  cortical  erosions.  Small  frontal  lobes, 
asymmetrical  hemispheres,  and  a  narrow  grey  substance.  The 
basal  arteries  were  atheromatous. 

The  author  refers  to  two  other  similar  cases  which  have  been 

*   Neurolog.  Ceniralbl.,  1898,  p.  558. 


358  •       Insane  Aments 

described,  and  in  a  subsequent  note  states  that  the  asylum  register 
at  Ferrara  shows  the  existence  of  a  fourth. 

Dementia. — Many  aments  become  demented  in  their  later  years, 
and  secondary  dementia  is  the  natural  termination  of  most  of  these 
cases  of  insanity,  its  advent  depending  chiefly  upon  the  type  and  the 
frequency  with  which  recurrences  occur.  Occasionally  a  condition 
of  primary  dementia  occurs  in  adolescents,  which  is  clinically  very 
similar  to  dementia  praecox.  The  patient  becomes  apathetic,  idle, 
and  neglectful,  and  eventually  quite  incapable  of  any  occupation. 
With  this  there  may  be  present  echolalia  and  certain  stereotyped 
mannerisms;  but  neither  delusions,  exaltation,  or  depression.  Plas- 
kuda*  has  described  a  series  of  fifteen  cases  of  dementia  praecox 
which  occurred  in  aments  resident  in  the  Idiot  Asylum  at  Liibben. 
Generally  speaking,  however,  primary  dementia  in  j'oung  aments 
is  of  such  rare  occurrence  that  its  presence,  without  antecedent 
insanity  or  epilepsy,  is  nearly  always  indicative  of  juvenile  general 
paralysis.  In  the  insanity  accompanying  epilepsy,  or  even  in  severe 
epilepsy  without  insanity  in  these  patients,  dementia  is  usually 
ushered  in  fairly  early.  In  the  sudden  and  violent,  but  short-lived, 
storms  of  the  emotional  type^  on  the  other  hand,  it  is  late,  and  I 
have  known  such  patients  show  no  sign  of  dementia  after  many 
years.  The  ordinary  attacks  of  insanity  seem  to  lie  midway 
between  these  two  extremes,  and  in  most  of  my  cases  definite 
symptoms  of  dementia  were  observable  \vithin  about  eight  years 
of  the  first  attack. 

It  is  thus  seen  that  in  the  life-cycle  of  the  ament  we  may  have 
an  epitome  of  all  the  main  varieties  of  mental  disease.  Beginning 
with  a  defective  brain,  he  may  early  show  signs  of  mental  instability 
and  imperfect  function;  this  passes  on  into  various  types  of  in- 
sanity, and  finally  culminates  in  complete  degeneration  of  all  the 
little  faculty  he  once  possessed — dementia. 

*  W.  Plaskuda,  Allgem.  Zeits.  f.  Psychiat.,  Band  Ixxvi.,  Heft  i. 


CHAPTER  XVII 
MENTAL  TESTS  AND  CASE-TAKING 

The  diagnosis  of  the  severe  grades  of  mental  deficiency  is  usuall}* 
made  without  much  difficulty;  but  that  of  the  mildest  degree  is 
by  no  means  so  easy,  and  often  can  only  be  achieved  after  a  careful 
study  of  the  case  in  all  its  bearings,  combined  with  a  very  con- 
siderable experience  on  the  part  of  the  observer.  Such  diagnosis  is 
now  not  infrequently  called  for,  both  in  the  case  of  children  and 
adults.  For  instance,  the  advice  of  the  physician  may  be  sought 
on  behalf  of  a  child  who  seems  dull,  unable  to  cope  with  his  lessons, 
or  whose  conduct  is  becoming  perverse  and  antisocial;  in  the  case 
of  adults  he  may  be  required  to  examine  and  give  evidence  on 
account  of  incendiarism,  stealing,  or  other  more  serious  offence,  or  he 
may  be  called  upon  to  give  an  opinion  as  to  the  capacity  of  an 
individual  for  managing  his  affairs.  In  any  of  these  instances  the 
question  of  the  presence  or  absence  of  mental  defect  will  arise,  and 
it  is  one  which  may  tax  the  ability  and  experience  of  the  physician 
to  the  full.  But  there  can  be  no  doubt  that,  under  the  Mental 
Deficiency  Act  of  1913,  the  number  of  such  cases  will  be  greatly 
increased,  and  that  consequently  the  diagnosis  of  mental  defect 
will  come  to  occupy  a  very  important  place  in  medical  practice. 
Such  diagnosis  necessitates  methods  of  examination  which  not  only 
differ  very  considerably  from  those  in  ordinary  use,  but  to  which 
little  attention  has  hitherto  been  given  by  the  practitioner,  and 
since  the  legal  position  of  the  mentally  defective  now  renders  it 
extremely  advisable  that  such  examination  should  be  systematic 
and  carefully  recorded,  I  propose  in  this  chapter  to  give  an  account 
of  the  methods  of  examination  and  case-taking.  We  shall  then  be 
better  able  to  deal  with  the  matter  of  diagnosis  in  the  following 
chapter. 

The  examination  of  a  person  regarding  whom  there  is  a  question 

359 


360  Mental  Tests  and  Case-Taking 

of  mental  defect  resolves  itself  into  three  lines  of  inquiry:  firstly, 
with  regard  to  his  previous  history;  secondly,  his  family  history; 
and  thirdly,  his  present  state.  The  first  and  second  of  these  do  not 
differ  from  similar  inquiries  which  the  physician  is  called  upon  to 
make  in  regard  to  ordinary  patients,  although  it  is  necessary  to  have 
a  knowledge  of  those  factors  which  are  of  special  significance  and 
concerning  which  information  must  be  obtained.  The  third  line  of 
inquiry  embraces  methods  of  examination  which  are  very  different 
from  those  in  ordinary  use,  and  these  we  shall  now  consider.  I 
shall  conclude  with  a  form  of  case-taking  which  I  have  found  of 
practical  utility. 

MENTAL  TESTS. 

During  recent  years  very  great  advances  have  been  made  in 
experimental  psychology,  and  many  volumes  have  now  been  written 
dealing  with  the  subject  of  mental  tests.  Although  many  of  these 
tests  are  still  in  the  experimental  stage,  and  will  themselves  require 
to  be  tested  before  their  value  can  be  accurately  determined,  there 
can  be  no  doubt  that  the  science  is  one  which  has  a  great  future 
before  it  in  the  elucidation  of  the  problem  of  mental  development 
and  the  practical  work  of  education.  This  importance,  indeed, 
has  long  been  recognized  in  America,  and  for  seventeen  years  there 
has  been  in  existence  a  Psychological  Clinic  at  the  University  of 
Pennsylyania  for  the  express  purpose  of  scientifically  studying  and 
advising  as  to  the  education  of  abnormal  children.  An  exceedingly 
interesting  account  of  the  organization  and  operation  of  this  clinic, 
together  with  much  valuable  information  regarding  mentally  and 
morally  abnormal  children,  has  been  recently  given  by  Dr.  Arthur 
Holmes,*  the  Assistant-Director.  In  England,  however,  the  value 
of  such  methods  has  not  yet  been  officially  appreciated,  and  although 
the  scientific  study  of  the  school-child  has  long  received  attention 
at  the  hands  of  a  number  of  highly  qualified  experts,  the  psycho- 
logical clinic  is  still  a  thing  of  the  future. 

But  it  must  be  confessed  that  the  applicability  of  the  methods  of 
the  psychological  laboratory  to  the  defective  mind  is  limited.  Most 
of  them  require  an  intelligence  and  co-operation,  besides  an  amount 
of  time  and  apparatus,  which  not  only  render  them  unsuited  for 
the  purpose  of  diagnosing  the  condition  we  are  dealing  with,  bjut 
which  makes  their  use  impossible  in  the  consulting-room.     And 

*  A.  Holmes,  "  The  Conservation  of  the  Child,"  Philadelphia,  1912. 


Mental  Tests  361 

in  the  case  of  the  adult,  the  test  of  conduct,  as  revealed  by  his  life- 
history,  is  often  a  criterion  of  far  greater  value  than  is  his  response 
to  laboratory  tests.  Nevertheless,  mental  tests,  if  properly  under- 
stood and  apphed,  have  a  distinct  value  which  it  is  impossible  to 
over-rate.  They  supply  us  with  definite  information  regarding 
defects  and  abnormalities  of  working  which,  when  rightly  inter- 
preted, are  of  the  utmost  assistance  to  diagnosis,  and  they  will  be 
the  means  of  carrying  us  on  from  that  imperfect  knowledge  of  the 
defective  mind  with  which  we  have  hitherto  been  compelled  to  be 
satisfied  to  a  more  precise  and  scientific  knowledge  of  the  subject. 

These  tests  have  been  designed  to  further  several  ends.  For 
one,  the  ascertainment  of  information  regarding  the  construction 
and  working  of  the  normal  mind ;  for"  another,  the  erection  of 
standards  of  comparison;  and  for  another,  the  detection  of  abnor- 
malities and  defects.  The  scope  of  this  book  is  that  of  the  defective 
mind  only,  and  my  present  purpose  is  to  discuss  the  diagnosis  of 
such  defect;  consequently  I  shall  confine  my  remarks  to  such  tests 
as  have  definite  diagnostic  value.  For  fuller  information  the  works 
of  Whipple,  Holmes,  Myers,  Titchener,  and  others  may  be  con- 
sulted, to  which  I  here  express  my  great  indebtedness.* 

Before  describing  these  tests,  a  few  preliminary  remarks  regarding 
their  use  may  not  come  amiss.  In  the  first  place  it  is  to  be 
remarked  that  no  mental  test  is  a  graduated  standard,  hke  a 
yard  measure,  which  will  automatically  register  the  quantity  and 
quality  of  any  particular  psychological  function.  Acuteness  of 
observation,  clinical  experience,  and  some  knowledge  of  psychology 
are  all  required  on  the  part  of  the  observer,  and  without  these  failure 
will  be  inevitable.  As  a  matter  of  fact,  the  knowledge  gained  is 
far  more  dependent  upon  the  power  of  interpretation  possessed  by 
the  examiner  than  upon  the  nature  of  the  test  applied,  and  an 
experienced  physician  will  form  a  better  estimate  of  a  patient's 
mental  capacity  from  a  short  conversation  than  will  the  inex- 
perienced and  unobservant  from  the  whole  series  of  laboratory 
experiments.     I   entirely  agree  with  Dr.   Holmes  when  he  says: 

*  G.  M.  Whipple,  "  Manual  of  Mental  and  Physical  Tests,"  Baltimore, 
U.S.A.,  1910.  This  is  an  excellent  compilation,  giving  all  the  most  recent 
tests,  full  instructions  as  to  their  use,  and  an  account,  with  copious  references, 
of  the  results  obtained  by  many  observers. 

C.  S.  Myers,  "  Textbook  of  Experimental  Psychology,"  Cambridge, 
1911;  also  "  Introduction  to  Experimental  Psychology,"  igii. 

E.  B.  Titchener,  "  Experimental  Psychology,"  New  York,  igoi. 


362  Mental  Tests  and  Case-Taking 

"  How  well  he  accomplishes  his  assigned  tasks,  or  plays  his  games 
or  is  able  to  acquire  the  ordinary  rudiments  of  an  education  under 
the  same  conditions  that  obtain  with  normal  children,  are  of  far 
more  importance  for  predicting  his  mental  ability  to  hold  his  own 
in  society  than  many  a  fine-drawn  technical  test  worked  out  in  a 
laboratory."* 

Underneath  the  bell  of  my  front  door  is  a  brass  plate  inscribed, 
"  Please  do  not  ring  unless  an  answer  is  required."  It  is  intended 
to  save  my  servants  unnecessary  labour,  not  to  test  the  intelligence 
of  callers ;  but  I  often  think  it  affords  a  mine  of  information  regarding 
them.  One  person  will  come  with  a  note,  put  his  hand  on  the  bell, 
see  the  plate,  take  his  hand  away,  drop  the  note  in  the  letter-box, 
and  go  away.  Another  will  desist  from  pulling  the  bell,  but  hammer 
at  the  knocker,  and  give  the  maid  a  note  with  the  remark  that, 
"  There's  no  answer."  Another  will  read  the  notice,  put  the  letter 
in  the  box,  give  a  vigorous  pull  at  the  bell,  and  then  retire.  Yet 
another,  with  a  message  for  which  he  has  been  told  to  await  an 
answer,  will  stand  helplessly  bewildered  because  the  plate  says, 
"  Do  not  ring."  I  have  little  doubt  that  by  this  simple  means  a 
good  clinician  would  arrive  at  a  tolerably  accurate  estimate  of  the 
mental  status  of  most  of  these  people. 

In  conducting  these  tests  it  is  essential  to  gain  the  confidence  of 
the  subject  and  to  put  him  at  his  ease.  This  necessitates  time  and 
patience;  but  the  physician  who  is  hurried  and  perfunctory  will 
inevitably  confuse  his  patient  and  come  to  erroneous  conclusions. 
I  regard  this  maxim  as  fundamental.  Whatever  test  is  used,  the 
particular  information  it  is  desired  to  elicit  must  be  quite  clear  in 
the  mind  of  the  observer,  and  when  the  result  is  obtained,  it  must 
be  noted  at  once,  together  with  such  comments  as  are  necessarj'" 
to  make  the  reaction  quite  clear  on  a  subsequent  reading.  Finally, 
I  need  hardly  say  that  the  tests  to  be  described  are  a  catalogue  of 
what  may  be  used  in  particular  cases  rather  than  a  list  to  be  gone 
through  in  every  instance. 

Vision. — If  the  patient  knows  the  letters,  the  ordinary  Snellen's 
types  may  be  used.  If  he  does  not,  the  E-test  described  by  Dr. 
C.  S.  Myers,  f  or  a  series  of  pictures  of  different  animals  of  varying 
sizes  pasted  on  a  card  may  be  made  to  answer  the  same  purpose. 
If  it  is  desired  to  test  colour  vision,  he  may  be  asked  to  match 

*  A.  Holmes,  op.  cit.,  p.  185. 
t   C.  S.  Myers,  op.  cit. 


Mental  Tests  363 

coloured  wools,  or  use  may  be  made  of  small  wooden  cubes,  each 
side  of  which  is  painted  a  different  colour.  Boxes  of  these  are 
obtainable  from  most  toy-shops.  Any  serious  visual  defect  will 
necessitate  a  retinoscopy  and  the  prescription  of  suitable  glasses. 

Hearing. — The  manner  in  which  the  patient  responds  to  the 
voice  of  the  examiner,  which  may  be  varied  from  the  ordinary  tone 
to  a  whisper,  is  usually  a  sufficient  test.  It  may  be  advisable  not 
to  allow  the  lips  to  be  seen.  In  cases  where  there  is  any  doubt  a 
watch  ma}^  be  held  at  varying  distances  from  each  ear  in  turn,  or 
he  may  be  tested  by  a  bell,  whistle,  or  tuning-fork. 

Taste. — ^When  it  is  necessary  to  investigate  this  sense,  it  may  be 
tested  by  touching  the  tongue  with  powdered  salt,  sugar,  starch, 
and  quinine,  and  noting  the  subject's  power  of  appreciation. 

Smell  is  tested  by  allowing  the  child  to  sniff  bottles  containing 
such  essences  as  peppermint,  cloves,  almonds,  and  vanilla.  He  is 
not  required  to  name,  but  only  to  distinguish  between  them. 

Cutaneous  Sensibility  may  be  tested  by  the  response  to  the  prick 
of  a  needle;  by  the  application  of  test-tubes  filled  with  iced  and 
hot  water;  and  by  getting  the  blindfolded  child  to  say  which  is 
rough  and  smooth  of  a  piece  of  velvet,  wood,  and  sandpaper,  etc. 
I  often  make  use  of  a  little  bag  in  which  is  placed  a  miscellaneous 
collection  of  small  objects  such  as  a  penny,  marble,  button-hook, 
match-box,  and  reel  of  cotton.  The  patient  is  required  to  say 
what  they  are  by  placing  his  hand  in  the  bag  without  seeing  them, 
and  I  find  this  to  be  interesting  as  well  as  instructive. 

Attention. — By  the  measure  of  attention  is  meant  the  quantitative 
capacity  of  the  person  for  mental  effort  in  one  direction.  As  we 
have  seen  in  the  preceding  pages,  this  varies  very  greatly  in  aments, 
and  is  undoubtedly  a  very  important  factor  in  their  ability  or 
otherwise  for  learning  and  useful  employment.  But  its  degree  is 
dependent  upon  interest;  consequently,  in  order  to  gauge  its 
amount  it  is  desirable  to  apply  such  tests  as  are  not  only  devoid 
of  interest,  but  which  may  even  be  distasteful.  If  these  fail,  re- 
course may  then  be  had  to  others  of  a  more  interesting  nature. 
The  following  tests  are  those  I  have  found  most  generally  suitable 
for  the  milder  cases : 

I.  Bourdon's  Cancellation  Test. — The  patient  is  given  a  card  con- 
taining several  lines  of  capital  letters  printed  at  random  from  a 
pile  of  mixed  type  ("  pied  "  material),  and  is  required  to  cross  out 
all  those  of  a  certain  character.    Perhaps  the  simplest  letter  to  take 


364  Mental  Tests  and  Case-Taking 

is  0.  It  is  rendered  more  difficult  by  asking  him  to  cross  out  C 
or  B,  which  are  Hable  to  be  mistaken  for  G  or  R,  and  the  difficulty 
is  further  increased  if  several  letters  are  required  to  be  cancelled 
at  the  same  time.  The  number  of  mistakes  and  the  time  taken 
is  to  be  noted.  If  the  "  pied  "  material  is  not  to  hand,  an  ordinary 
piece  of  printed  matter  will  serve  the  purpose. 

2.  Card-Sorting. — The  patient  is  given  a  well-shuffled  pack  of 
"  Snap  "  cards,  and  is  required  to  sort  them  out  into  heaps  according 
to  the  pictures.  This  test  is  decidedly  more  interesting  than  the 
former  one;  it  may  be  made  less  so,  and  more  difficult,  if  ordinary 
playing  cards  be  substituted  for  the  "  Snap  "  cards  and  the  subject 
required  to  sort  them  into  suits. 

Association. — A  very  fair  idea  of  the  patient's  power  of  associa- 
tion will  be  obtained  by  asking  him  to  tell  all  he  can  about  such 
familiar  objects  as  a  cat,  cow,  chair,  or  knife.  Where  more  definite 
information  is  desired,  the  following  tests  are  suitable  for  the  milder 
grades : 

1.  Part-Wholes  Test.— The  patient  is  given  a  card  on  which  are 
printed  ten  words  such  as — Door,  letter,  leaf,  page,  pillow,  button, 
nose,  cover,  engine,  glass.  The  examiner  instructs  the  patient 
as  follows:  "  I  shall  give  you  a  paper  on  which  are  printed  ten 
words.  I  want  you,  as  rapidly  as  you  can,  to  give  for  each  word 
the  name  of  the  whole  thing  of  which  the  word  is  a  part.  For 
instance,  if  the  word  "  fur  "  were  given,  you  would  name  a  thing  that 
"  fur  "  is  a  part  of,  like  "  cat  " ;  for  "  hand  "  you  might  say  "  arm  " 
or  "  watch."  The  examiner  writes  down  the  words  as  the  patient 
gives  them,  and  if  the  time  be  taken,  useful  comparisons  may  be 
instituted  between  different  subjects. 

2.  Genus-Species  Test. — The  principle  is  the  same  as  in  the  pre- 
ceding test,  but  the  words  given  are  those  of  a  general  class,  and 
the  patient  is  required  to  name  particular  instances  of  that  class. 
For  example,  correct  answers  for  "  animal  "  would  be  any  kind  of 
animal;  for  "  man  "  any  nationality;  for  "geography,"  such  words 
as  a — River,  cape,  bay,  etc.;  for  "  money,"  any  particular  coins. 

3.  Opposites  Test. — The  patient  is  given  a  card  containing  a  list 
of  twenty  words,  and  is  required  to  give  for  each  one  a  word  having 
the  opposite  meaning.  The  lists  vary  in  difficulty,  those  in  List  A 
being  such  as — Bad,  inside,  slow,  short,  etc. ;  those  in  List  C  being 

.  such  as — Proud,  obscure,  superior,  sane,  obnoxious,  etc.  The  number 
of  mistakes  and  the  time  taken  are  noted. 


Mental  Tests  365 

Memory.^ — An}'  marked  defect  of  recent  memory  will  be  detected 
if  the  patient  be  asked  to  give  an  account  of  what  he  has  been 
doing  that  da}',  what  he  had  for  breakfast,  what  he  saw  on  his 
way,  and  so  on.  His  remote  memory  may  be  similarly  tested  by 
getting  him  to  describe  some  former  happening,  such  as  the  holiday 
last  year,  a  former  school,  etc.  It  is  necessary  to  remember  that  a 
child  may  make  up  for  lack  of  memory  by  invention,  and  his 
accounts  should  always  be  checked  by  inquiries  of  an  independent 
source.  More  special  tests  for  memory  are  the  following:  Arrange 
on  a  board  twelve  common  articles  [e.g.,  knife,  pen,  cork,  penny, 
match,  etc.),  let  the  subject  look  at  them  for  sixty  seconds,  and  then 
remove  and  ask  him  to  enumerate  them.  Instead  of  common 
objects,  the  subject  may  be  shown  a  series  of  cards  on  which  are 
printed  varying  numbers  of  nonsense  syllables  or  figures.  Each 
card  is  exposed  for  a  definite  time,  and  the  exposures  continued 
until  he  can  repeat  them  without  error.  The  number  of  readings 
necessary  for  this  gives  the  span  of  immediate  visual  memory. 
The  span  of  auditory  memory  may  be  similarly  tested  if  the  con- 
tents of  the  cards  are  read  to  the  patient  and  not  seen  by  him. 
Retentiveness,  or  perseveration,  may  be  gauged  if  the  patient  be 
again  asked  to  repeat  the  objects,  syllables,  or  numbers  on  the 
following  day  or  at  the  end  of  the  interview. 

Tests  of  Description  and  Report. — Closely  alhed  to  the  foregoing 
tests  of  association  and  memory  are  those  known  as  tests  of  descrip- 
tion and  report,  which  may  here  be  mentioned.  The  object  of  these 
is  to  determine  the  subject's  general  capacity  to  attend,  observe, 
and  recall  what  he  has  seen.  There  is  no  doubt  that  they  are  of 
considerable  value,  and  that  an  acute  observer  is  enabled  by  their 
means  to  form  a  very  good  estimate  of  the  general  mental  capacity 
of  a  patient.  As  Dr.  Whipple  very  truly  says,  the  activity  here 
investigated  is  not  only  a  more  complex  psychical  process  than  that 
examined  by  the  ordinary  tests  of  attention  and  perception;  but  it 
"  is  more  akin  to  that  demanded  in  everyday  life,  and  it  is  for  this 
reason  that  these  tests  have  been  felt  to  possess  a  peculiar  value, 
particularly  in  the  study  of  individual  differences  in  mental  con- 
stitution and  mental  efficiency."     The  tests  are  as  follows: 

I.  Description  of  an  Object. — The  patient  is  given  some  object, 
such  as  a  cancelled  postage  stamp,  a  cigarette,  a  box  of  matches, 
etc.,  and  instructed  to  write  a  description  of  it,  so  that  one  who 
had  never  seen  it  before  would  know  all  about  it.     Ten  minutes 


366  Mental  Tests  and  Case-Taking 

or  more  are  allowed  for  the  task,  according  to  how  the  patient  is 
getting  on. 

2.  Fidelity  of  Report  [Aussage  Test). — One  method  of  this  consists 
in  showing  the  patient,  for  a  period  of  half  to  one  minute,  a  series 
of  six  small  objects  like  those  used  in  testing  memory;  but  instead 
of  him  being  merely  required  to  enumerate  them,  he  is  closely 
interrogated  regarding  the  minute  features  of  each  one — e.g.,  the 
value  of  the  coin  ?  is  it  a  head  or  tail  ?  whose  head  ?  what  date  ? 
is  it  bright  or  dull  ?  how  is  it  fastened  to  the  board  ?  etc.  Instead 
of  a  collection  of  objects  a  series  of  pictures  may  be  shown,  and 
the  patient  subsequently  closely  questioned  regarding  each  detail. 
This  is  the  method  of  Stern,*  who  has  experimented  with  it  very 
extensively,  and  is  its  chief  exponent. 

These  tests  are,  of  course,  only  suited  to  the  mildest  grades  of 
mental  defect,  and  aU  such  persons  show  a  marked  inferioritj^  as 
compared  with  the  average  normal. 

Suggestibility — Facility. — As'  we  have  seen  in  preceding  pages, 
the  conduct  of  many  aments  is  antisocial  or  immoral  by  reason  of 
their  ready  amenability  to  evil  influences,  and  in  some  cases  it 
may  be  desirable  to  give  an  actual  demonstration  of  this  facility. 
There  are  many  tests  designed  to  this  end,  false  suggestions  being 
made  by  size-weight  illusions,  by  lines  of  varying  length,  and  by 
bodies  of  different  temperature.  Since,  however,  in  everyday  life 
the  yielding  is  more  often  the  result  of  personal  influence  or  in 
response  to  a  command,  the  most  suitable  tests  are  those  which 
utilize  this  factor,  and  probably  the  "  line  test  "  as  used  by  Binet 
is  the  best  for  the  purpose.  It  is  as  follows: — Materials  required: 
a  sheet  of  cardboard,  on  which  are  drawn  twenty-four  parallel 
straight  ^ines,  ranging  in  length  from  12  to  104  millimetres  by 
increments  of  4  millimetres.  The  lines  of  all  begin  at  the  same 
distance  from  the  left-hand  margin,  are  7  millimetres  apart,  and  are 
numbered  in  order  of  their  length  from  i  to  24.  This  is  called 
the  "  comparison  card."  Three  rectangular  pieces  of  cardboard, 
about  12  by  20  centimetres,  on  each  of  which  is  drawn  a  single 
straight  line.  These  three  stimulus  lines  correspond  to  numbers  6, 
12,  and  18  of  the  twenty-four  comparison  lines,  and  are  accord- 
ingly 32,  56,  and  80  miUimetres  long  respectively.  Method :  Show 
the  subject  the  card  of  comparison  lines,  and  explain  their  number- 
ing. Then  show  him  the  first  stimulus  Hne  (32  millimetres),  and 
*  L.  W.  Stern,  "  Zur  Psychologic  der  Aussage,"  Berlin,  1902. 


Mental  Tests  367 

tell  him  to  look  at  it  carefully.  After  four  seconds  the  stimulus 
card  is  removed  and  the  comparison  card  again  presented,  and  he 
is  asked  to  denote  the  number  of  the  line  that  is  the  same  length  as 
that  he  has  just  been  looking  at.  Upon  his  reply  the  observer 
says,  "Are  you  quite  sure  ?  Isn't  it  that  ?"  indicating  the  next 
in  length.  If  the  subject  persists,  the  question  is  again  repeated; 
if  he  still  persists  he  is  recorded  as  "  resisting,"  and  a  similar  trial 
is  made  with  the  other  two  stimulus  lines.  If  he  acquiesces  in  the 
suggestion,  the  observer  points  to  another  line  still  longer  than  the 
stimulus  line,  and  proceeds  from  line  to  line  until  the  suggestion 
has  been  resisted  twice. 

Emotional  Reaction. — The  emotional  disposition  of  the  patient 
will  usually  be  best  revealed  by  inquiries  as  to  his  general  behaviour. 
If  necessary,  it  may  be  tested  by  noting  his  response  to  pictures 
designed  to  provoke  sorrow,  sympathy,  anger,  fear,  mirth,  etc. 
Recently  it  has  been  stated  that  the  mental  content  may  be  revealed 
in  an  extraordinary  way  by  supplying  the  subject  with  a  printed 
list  of  a  hundred  carefully  selected  words  and  telling  him  to  read 
each  of  them,  and  at  once,  without  any  consideration  or  delay, 
write  down  the  word  which  comes  into  his  mind.*  In  the  case  of 
the  mentally  defective,  however,  the  response  is  usually  so  slow 
that  this  method  is  not  suitable.  In  normal  persons  the  train  of 
thought  is  frequently  tested  by  the  device  of  requiring  the  subject 
to  write  as  rapidly  as  possible  every  word  which  comes  into  his  head 
until  one  hundred  have  been  written.  The  list  is  then  subjected 
to  careful  analysis,  and  often  supplies  valuable  information  regard- 
ing the  rate  and  quality  of  thought,  the  mode  of  association,  etc. 
This,  however,  is  rarely  applicable  to  aments. 

Judgment  and  Reasoning.  —  Reasoning  is  a  highly  complex 
mental  process  necessitating  attention,  observation,  association,  and 
memory ;  but  perhaps,  above  aU,  the  ability  to  appreciate  and  com- 
pare essentials.  The  best  test  of  a  person's  reason  is  afforded  by  his 
conduct  and  behaviour  under  varying  circumstances  of  real  life, 
and  in  dealing  with  adults  in  particular,  the  physician  should  never 
neglect  to  make  a  thorough  investigation  regarding  this.  In  cases 
where  such  information  is  not  forthcoming,  and  in  children,  the 
following  tests  may  be  made  use  of.    They  are  arranged  in  order  of 

*  See  A.  Holmes,  op.  cit.  ;  also  an  interesting  article  by  C.  Burt  on  "  Ex- 
perimental Tests  and  their  Relation  to  General  Intelligence,"  in  Journal  of 
Experimental  Pedagogy,  November,   191 1. 


368 


Mental  Tests  and  Case-Taking 


difficulty,  and  failure  in  the  first  four  indicates  a  very  low  grade  of 
defect,  whilst  the  last  two  or  three  can  usually  be  accomplished  by 
normal  children  of  ten  years  of  age,  but  not  b}^  the  feeble-minded. 

1.  Tell  the  subject  to  go  and  sit  on  a  chair  which  is  turned  upside 
down  or  occupied  by  some  bulky  article. 

2.  Tell  him  to  get  an  article  from  a  shelf  which  is  beyond  his 
reach,  but  which  might  be  reached  if  he  stood  on  a  chair. 

3.  Tell  him  to  go  outside  the  room  when  the  door  is  locked  and 
the  key  hanging  on  the  door  in  a  conspicuous  position. 

4.  Turn  his  coat  sleeves  inside  out  and  tell  him  to  put  it  on. 

5.  Give  him  a  knotted  cord  to  untie. 

6.  Tell  him  to  get  a  particular  ke}^  off  a  split  ring. 

7.  Identify  objects  from  drawing  showing  only  portions. 

8.  Show  an  unfamiliar  object  and  ask  him  to  describe  its  use. 

9.  Trace  the  following  figure  without  taking  pencil  off  or  going 
over  a  line  twice. 


S 


Under  this  heading  we  may  mention  what  is  known  as  the  "  com- 
pletion method  "  of  Professor  Ebbinghaus,*  which  consists  in  the 
subject  being  required  to  restore  the  words,  or  at  all  events  the 
meaning,  to  a  passage  from  which  certain  s^dlables,  words,  or 
phrases  have  been  deleted.  It  is  obviously  a  test  the  simplicity 
or  difficulty  of  which  may  be  varied  within .  a  very  wide  range, 
according  to  the  nature  of  the  passage  used  and  the  number  of 
words  deleted,  and  Ebbinghaus  and  others  attach  very  great  value 
to  it;  but  it  seems  on  the  whole  decidedly  more  applicable  to  the 
non-defective  than  to  the  defective  mind. 

General  Intelligence  and  Capacity. — The  tests  hitherto  considered 
have  been  designed  for  the  purpose  of  gauging  the  activity,  and 
noting  abnormalities,  of  particular  psychological  processes.     It  is 

*  H.  Ebbinghaus,  "  Ueber  eine  neue  Methode  zur  Priifung  geistiger 
Fahigkeiten,"  etc.,  Zeiisch.  f.  Psychologie  iind  Physiologic  der  Sinnesorgane, 
1897- 


Mental  Tests  369 

not,  of  course,  thereby  to  be  inferred  that  the  processes  of  mind  act 
independently  of  one  another,  and  that  we  can  really  separate  them 
in  this  way.  As  a  matter  of  fact,  most  of  the  foregoing  tests  will 
not  fail  to  supply  information  regarding  many  other  functions  than 
the  one  to  which  the  test  is  directed.  It  is,  nevertheless,  con- 
venient to  speak  of  them,  and  to  use  them,  as  tests  of  the  "  ele- 
ments "  of  mind,  and  the  sum  of  the  results  so  obtained  does  un- 
doubtedly enable  a  tolerably  accurate  estimate  to  be  formed  of  the 
capacity  and  working  of  the  mind  as  a  whole.  But  to  go  through 
the  whole  of  these  tests  is  tedious,  and  requires  more  time  than  is 
at  the  disposal  of  the  clinician;  accordingly,  in  actual  practice,  it 
is  often  a  great  advantage  if  we  can  arrive  at  an  estimate  of  the 
net  resultant  of  the  mental  capacity  of  the  individual  by  a  simpler 
method.  In  many  instances  this  is  possible,  and  I  think  the  two 
following  methods  (I  hardly  like  to  dignify  them  by  the  name 
"  tests  "),  which  I  have  now  been  in  the  habit  of  using  for  many 
years,  do  afford  sufficient  information  for  purposes  of  diagnosis  in 
the  majority  of  cases. 

I.  Range  of  Information. — Every  mentally  normal  child  has 
within  him  an  innate  capacity  which  causes  him  to  notice,  feel, 
speculate  upon,  discriminate  between,  and  so  acquire  information 
regarding  the  objects  of  the  world  in  which  he  lives.  He  does  this 
in  his  play  and  in  the  absence  of  any  formal  instruction,  and  unless 
his  environment  has  been  very  unusually  adverse,  he  soon  becomes 
acquainted  with  the  names,  uses,  and  many  other  details  regarding 
the  things  by  which  he  is  surrounded.  With  the  mentally  deficient 
child  it  is  different.  His  intrinsic  lack  of  initiative,  observation, 
attention,  memory,  ideation,  and  reason  result  in  a  defective  range 
of  information  which  contrasts  in  a  most  marked  manner  with  that 
of  the  normal  child,  and  a  little  judicious  questioning  cannot  fail  to 
bring  out  the  difference  in  the  clearest  possible  way.  The  method 
to  which  I  attach  great  practical  value,  therefore,  is  to  engage  the 
child  in  conversation  regarding  the  incidents  and  surroundings  of 
his  daily  life.  His  knowledge  of,  and  manner  of  response  to,  such 
simple  questions  as  "  What  is  a  cat  or  a  horse  ?"  "  What  is  it  for  ?" 
"  What  does  it  do  ?"  and  the  like,  will  often  afford  all  the  informa- 
tion as  to  his  state  of  mind  which  is  needed  by  a  physician  who 
knows  how  to  interpret  the  answers  so  given.  Two  things  are 
needed — a  general  knowledge  of  the  intellectual  range  of  the  average 
normal  child,  which  every  practitioner  should  possess;  and  a  know- 

24 


3/0  Mental  Tests  and  Case-Taking 

ledge  of  the  child's  environment.  I  mention  this  latter  because  I 
have  known  a  town-bred  child  who  had  migrated  to  a  country  school 
stigmatized  by  the  teacher  as  mentally  deficient  because  he  did  not 
know  what  a  blackbird  was  like  !  He  had  never  seen  nor  heard 
of  one. 

2.  Dissected  Picture  Test. — This  test  is  a  modification  of,  and  was 
suggested  to  me  by,  the  now  popular  "  jig-saw  "  puzzles.  I  have 
used  it  for  several  years,  and  believe  it  to  be  one  of  the  most  simple 
and  practical  means  we  have  for  estimating  the  general  mental 
capacity  of  a  patient  as  seen  in  the  consulting-room.  It  is  not 
suggested  as  a  standard  of  measurement  for  the  comparison  of 
children  of  different  ages.  No  doubt  it  might  be  so  used  were  a 
sufiiciently  large  series  of  observations  made  with  the  same  pic- 
tures; but  I  regard  its  main  use  as  indicating  the  innate  capacity 
and  presence  of  abnormalities  in  the  individual.  It  is  as  foUows: 
A  series  of  pictures  mounted  on  stout  card  are  cut  up  into  squares 
of  equal  size,  so  that  each  square  will  fit  into  any  place  in  the 
picture.  The  pieces  of  one  picture  are  well  shuffled,  and  the  child 
required  to  reconstruct.  The  cutting  up  into  interchangeable- 
squares  has  this  advantage  over  the  ordinary  dissected  puzzles, 
that  no  guidance  is  obtained  by  the  particular  shape  of  the  piece, 
but  only  by  the  picture  itself.  I  have  a  series  of  six  such  dissected 
pictures.  The  simplest  of  all  really  consists  of  half  a  dozen  separate 
figures^ — i.e.,  a  policeman,  soldier,  sailor,  nurse,  wooden  doU,  and 
clown,*  and  each  figure  is  divided  into  three  parts — namely,  head 
and  neck,  body,  and  legs.  The  child  is  furnished  with  the  shuffled 
pieces  of  two,  three,  or  any  number  of  these  figures,  and  required 
to  put  them  together  in  their  proper  place.  All  feeble-minded 
children  of  school  age  can  do  this;  but  the  majority  of  imbeciles 
fail,  and  either  make  no  response  or  put  the  pieces  together  any  way, 
even  sideways.  The  most  difficult  picture  is  one  which  represents 
two  persons  ski-ing  amongst  a  mass  of  snow,  ice-peaks,  and  sky. 
The  complete  picture  consists  of  fifty-four  2-inch  squares,  and  I  have 
found  its  reconstruction  tax  the  attention,  perseverance,  and  judg- 
ment of  many  intelligent  persons.  It  is,  however,  divisible  into 
three  separate  pictures,  and  then  the  task  is  simpler.  Intermediate 
pictures  are  a  rural  scene,  with  river,  bridge,  sheep  crossing,  cottage 
amongst  trees,  and  church  in  the  distance.     This  consists  of  twelve 

*  The  "  Golly  Misfitz,"  published  by  G.  W.  Faulkner  and  Co.,  and  sold  by 
most  toy-shops,  answers  the  purpose  admirably. 


Mental  Tests  371 

2-inch  squares;  a  small  copy  of  Raphael's  Sistine  Madonna;  a  copy 
of  Dante  and  Beatrice,*  etc.  In  using  these  tests  for  children  I 
usually  begin  with  the  simplest;  it  is  brightly  coloured,  attractive, 
and  not  only  arouses  interest,  but  serves  to  restore  confidence  and 
put  the  child  at  his  ease.  If  this  is  done  without  difficulty,  I  then 
pass  on  to  the  next  in  the  series.  There  is  no  time-limit,  and  the 
value  of  the  test  lies  not  merely  in  whether  the  child  does  it  cor- 
rectly, but  in  his  manner  of  going  to  work  and  in  the  answers  he 
gives  to  a  few  questions  regarding  it  at  the  end.  This  test,  of 
course,  necessitates  observation,  ability  to  interpret,  and  some 
knowledge  of  psychology,  on  the  part  of  the  examiner;  but  given 
these,  I  know  of  no  single  test  which  will  give  more  information 
regarding  the  subject's  visual,  auditory,  and  tactile  sensation;  his 
association,  memory,  and  attention;  his  reasoning  and  judgment, 
initiative,  and  pertinacity,  as  well  as  the  quantity  and  quality  of 
his  muscular  movements. 

In  this  place  we  may  also  refer  to  the  tests  of  reading,  writing, 
and  arithmetic.  In  many  cases  the  physician  will  be  furnished 
with  information  regarding  the  patient's  accomplishments  in  these 
respects;  but,  apart  from  the  desirability  of  checking  these  state- 
ments, these  three  tests  are  capable  of  yielding  such  valuable 
information  that  they  may  often  be  used  with  great  advantage. 
All  that  is  needed  is  to  require  the  patient  to  read  a  few  simple 
paragraphs,  to  write  a  few  sentences  from  dictation,  and  then  to 
submit  him  to  a  few  questions  regarding  the  meaning  of  what  he 
has  read  or  written.  But  such  means  will  provide  the  observer 
with  data  regarding  vision  and  hearing,  obedience  to  command, 
attention,  memory,  capacity  for  ideation,  emotion,  -muscular  in- 
ertia, over-action  or  inco-ordination,  as  well  as  the  degree  of  his 
scholastic  retardation,  which  is  of  great  importance  to  diagnosis. 
With  regard  to  arithmetic,  I  usually  test  the  patient's  knowledge 
of  simple  addition  and  subtraction,  mentally  and  by  means  of 
coins. 

Movement. — The  quantity  and  quality  of  movement  is  not  only 
an  important  indication  of  a  person's  mental  action,  but  it  has  to 

*  I  selected  these  pictures  because  they  seemed  to  me  particularly  suited 
to  the  purpose  in  view;  but  there  is  nothing  special  about  them,  and  many 
others  would  do  equally  well.  All  that  is  necessary  is  that  they  should  form 
a  series,  that  they  should  represent  objects  which  are  familiar,  and  that  each 
should  be  cut  up  into  interchangeable  squares  of  a  suitable  size. 


372  Mental  Tests  and  Case-Taking 

be  taken  into  consideration  in  advising  as  to  treatment  and  occu- 
pation; hence  it  is  very  desirable  to  make  an  examination  on  this 
point.  The  quantity  of  movement — that  is,  whether  in  excess  or 
defect — is  readily  revealed  by  observation  of  the  manner  in  which 
almost  any  of  the  preceding  tasks  are  performed.  For  instance, 
in  one  person  the  response  will  be  slow,  laboured,  and  hesitating; 
whilst  in  another  action  is  quick,  excessive,  and  often  accompanied 
by  pronounced  tricks  and  habits.  Inco-ordination  of  the  hands 
is  readily  detected  by  such  simple  tests  as  requiring  the  subject 
to  write  a  sentence  from  dictation,  to  pick  up  a  pin  or  coin  from  a 
polished  table,  or  to  thread  a  needle;  inco-ordination  of  the  legs 
by  requiring  him  to  walk  along  a  line,  to  stand  on  one  leg,  and  to 
turn  round  quickly;  whilst  of  higher  levels  the  nature  of  speech 
may  afford  useful  indications.  Dr.  Warner's  tests  have  already  been 
referred  to  on  p.  128,  and  are  very  delicate  and  valuable  indications 
as  to  the  condition  of  the  patient's  motor  centres.  The  manner  in 
which  he  executes  these  imitation  movements  affords  a  very  good 
test  of  his  capacity  for  forming  motor  ideas;  whilst  his  obedience 
to  two  or  three  simple  commands  given  simultaneously,  such  as, 
"  Take  this  book  and  place  it  on  that  chair,  then  open  the  door  and 
walk  to  the  window,"  will  afford  an  indication  of  his  retentiveness 
of  motor  ideas  as  well  as  of  his  general  intelligence. 

Graduated  Serial  Tests. 

During  the  past  few  years  certain  series  of  tests  have  been 
■devised  for  the  purpose  of  gauging  the  mental  capacity  of  children 
according  to  age,  and  of  detecting  defects  and  abnormalities  in 
relation  to  normal  stages  of  development.  Of  these,  the  best- 
known  and  most  useful  are  those  of  MM.  Binet  and  Simon  of 
Paris,  and  De  Sanctis  of  Rome.  There  is  no  doubt  that  such 
serial  tests  have  a  very  great  value,  and  that  thej^  represent  a 
distinct  advance  in  our  methods  of  grading  normal  and  defective 
persons.  Those  of  MM.  Binet  and  Simon,  in  particular,  are  based 
upon  a  large  number  of  observations  conducted  with  the  greatest 
care  and  thoroughness,  and  the  tests  have  been  most  skilfully 
thought  out  and  arranged.  It  is  necessary  to  remember,  however, 
that  they  relate  to  French  children,  and  it  by  no  means  follows 
that  mental  evolution  proceeds  upon  precisely  similar  lines  in  the 
Anglo-Saxon  and  Latin  races.     Indeed,  experience  with  these  tests 


Binet-Simon  Tests  373 

would  seem  to  show  that  there  are  several  points  of  difference  be- 
tween children  of  the  two  races,  and  the  modifications  proposed 
by  Dr.  Goddard  appear  to  be  an  improvement  where  the 
tests  are  applied  to  English  and  American  children.  These  tests 
must  be  used  with  discrimination,  and  they  by  no  means  do  away 
with  the  need  for  skill,  patience,  and  deduction  on  the  part  of  the 
observer;  indeed,  Monsieur  Binet  definitely  states  that  for  the 
results  to  have  scientific  value  they  must  be  applied  by  persons 
possessing  a  thorough  practical  knowledge  of  experimental  psy- 
chology. In  skilled  hands,  however,  they  have  proved  of  very 
great  use,  and  Dr.  Goddard,  who  has  applied  them  to  400  feeble- 
minded and  2,000  normal  children,  says:  "  Experience  with  these 
tests  has  continually  reassured  us,  not  only  as  to  their  value,  but 
as  to  their  amazing  accuracy." 

MM.  Binet  and  Simon*  have  modified  and  altered  their  tests 
very  considerably  since  they  were  first  introduced,  and  Goddardf 
has  also  made  several  additions  and  improvements.  The  following 
is  the  latest  series,  as  modified  by  Goddard: 

BiNET-SiMON  Tests. 

Three  Years. 

(i)  Points  out  nose,  eyes,  and  mouth.     (2)  Repeats  two  numbers. 

(3)  Enumerates  the  objects  in  a  picture.  (4)  Knows  name.  (5)  Re- 
peats a  sentence  of  six  syllables — e.g.,  "  It  is  cold  and  snowing." 
(An  average  child  of  three  can  repeat  six,  but  not  ten,  syllables.) 

Four  Years. 

(i)  Tells  whether  a  little  boy  or  a  little  girl.  (2)  Names  familiar 
objects — e.g.,    key,    knife,    penny.     (3)    Repeats    three    numbers. 

(4)  Points  out  the  longer  of  two  lines. 

*  The  most  recent  work  of  the  original  authors,  MM.  Binet  and  Simon,  is 
contained  in  Bulletin  de  la  SociSte  Libre  pour  I'^tude  Psychologique  de  I' Enfant, 
April,  191 1. 

t  A  full  description  of  Dr.  Goddard's  procedure  is  given  in  "  The  Grading 
of  Backward  Children,"  issued  from  the  New  Jersey  Training  School,  1909, 
and  his  latest  revision  (as  described  above)  is  given  in  The  Training  SchooL 
June,  191 1.  For  some  important  criticisms,  results,  and  suggestions,  see 
also  Decroly  and  Degand  in  Archives  de  Psychologie,  1910. 


374  Mental  Tests  and  Case-Taking 

Five  Years. 

(i)  Tells  which  is  the  heavier  of  two  weights.  (2)  Copies  a 
square.  (3)  Repeats  a  sentence  of  ten  syllables — e.g.,  "  His  name  is 
John.  He  is  a  very  good  boy."  (4)  Counts  four  pennies.  (5)  Re- 
constructs an  oblong  card  which  has  been  cut  diagonally  into  two 

pieces. 

Six  Years. 

(i)  Knows  whether  it  is  morning  or  afternoon.  (2)  Says  what 
common  objects  are  used  for — e.g.,  fork,  chair,  table,  horse,  mother. 

(3)  Obeys  triple  commands — e.g.,  puts  key  on  chair,  brings  box, 
shuts  door.  (4)  Shows  right  hand  and  left  ear.  (5)  Says  which  is 
pretty  and  which  ugly  of  a  series  of  drawings  of  faces. 

Seven  Years. 

(i)  Counts  thirteen  pennies.  (2)  Describes  pictures.  (The  same 
pictures  as  for  three  years  are  used,  but  the  child  is  now  required 
to  describe  them,  not  merely  enumerate  objects.)  (3)  Notices  that 
certain   parts   are  missing   from   drawings   of  incomplete   figures. 

(4)  Can  copy  diamond.  (5)  Names  four  colours — e.g.,  red,  blue, 
green,  yellow. 

Eight  Years. 

(i)  Compares  two  things  from  memory,  such  as  fly  and  butterfly; 
wood  and  glass;  paper  and  cloth.  (2)  Counts  backwards  from 
20  to  I.  (3)  Repeats  the  days  of  the  week.  (4)  Counts  stamps, 
I,  I,  I,  2,  2,  2.     (5)  Repeats  five  figures,  4,  7,  3,  g,  5. 

Nine  Years. 

(i)  Gives  change  out'  of  shilling.  (This  is  done  with  the  toy-shop 
game,  using  real  money.)  (2)  Describes  common  objects  by  defi- 
nition superior  to  use.  (3)  Knows  date.  (4)  Repeats  the  months 
in  order.  (5)  Arranges  five  weights  in  order  of  heaviness  (each 
differs  by  3  grammes). 

Ten  Years. 

(i)  Knows  money:  £1,  los.,  2s.  6d.,  2s.,  is.,  6d.,  3d.,  id.,  |d. 
(2)  Copies  two  simple  designs  from  memory  after  having  seen 
them  for  ten  seconds  (a  prism  and  a  Greek  moulding).  (3)  Repeats 
six  figures:  8,  5,  4,  7,  2,  6; — 2,  7,  4,  6,  8,  i; — 9,  4,  i,  7,  3,  8. 
(4)  Comprehends  easy  questions.  (5)  Uses  three  given  words  in 
two  sentences. 


Binet-Simon   Tests  375 

Eleven  Years. 

(i)  Sees  absurdity  in  statements — e.g.,  "  An  unfortunate  bicycle- 
rider  broke  his  head  and  died  instantly;  he  was  picked  up  and  carried 
to  a  hospital,  and  they  do  not  think  he  will  recover."  "  I  have 
three  brothers,  Paul,  Ernest,  and  myself."  "  Someone  said,  '  If 
I  kill  myself  in  despair  some  day,  I  shan't  choose  Friday  to  do  it, 
because  Friday  brings  you  bad  luck  !'  "  "  We  met  a  man  who  was 
finely  dressed;  he  was  walking  along  the  street  with  his  hands  in 
bis  pockets,  and  twirling  his  cane."  (2)  Uses  three  given  words 
in  a  single  sentence.  (3)  Gives  sixty  words  in  three  minutes. 
{4)  Gives  three  rhymes — e.g.,  to  day,  spring,  mill,  etc.  (5)  Re- 
arranges a  simple  sentence  the  words  of  which  have  been  put  out 

of  order. 

Twelve  Years. 

(i)  Repeats  seven  figures:  2,  9,  6,  4,  3,  7,  5; — 9,  2,  8,  5,  i,  6,  4; — 
I,  6,  9,  7,  2,  3,  8.  (2)  Defines  charity,  justice,  goodness.  (3)  Repeats 
a  sentence  of  twenty-six  syllables — e.g.,  "  I  saw  in  the  street  a 
pretty  little  dog.  It  had  curly  brown  hair,  short  legs,  and  a  long 
tail."  (4)  Resists  suggestion  made  by  lines  of  different  lengths. 
(The  child  is  confronted  by  a  series  of  pairs  of  unequal  lines,  and 
this  is  then  followed  by  a  series  in  which  the  lines  are  equal,  and  he 
is  asked  which  are  the  longer.  The  test  is  passed  if  he  recognizes 
the  equality  of  the  second  series.)  (5)  Explains  an  incomplete 
account  of  some  incident — e.g.,  "  My  neighbour  has  been  having 
strange  visitors.  He  has  received  one  after  the  other  a  physician, 
a  lawyer,  and  a  clergyman.     What  has  happened  in  his  house  ?" 

Fifteen  Years. 

(i)  Interprets  an  impressionable  picture.  (2)  Interchanges 
hands  of  clock — e.g.,  if  6.20,  what  would  the  time  be  if  hour  and 
minute  hands  were  interchanged  ?  (3)  Writes  in  a  simple  code 
which  has  previously  been  explained  to  him.    (4)  Gives  the  opposites 

to  a  list  of  words  supplied. 

Adult. 

(i)  Cutting  paper.  (2)  Reversed  triangle.  (3)  Gives  differences 
between  pleasure  and  honour,  poverty  and  misery,  anger  and 
disdain,  etc.  (4)  Gives  the  differences  between  a  King  and  the 
President  of  a  Republic.  (5)  Gives  the  sense  of  a  selection  which 
has  been  read  to  him. 


3/6  Mental  Tests  and  Case-Taking 

In  using  the  above  tests,  the  pupil  is  first  examined  in  that  de- 
signed for  his  age,  and  this  is  followed  by  those  above  or  below, 
according  to  his  competence  or  incompetence.  All  questions 
under  any  age  must  be  answered  to  pass  that  age,  and  the  experi- 
menter records,  not  only  whether  the  child  passes  or  fails,  but  the 
nature  of  the  response  in  detail. 

De  Sanctis'  Tests. 

These  consist  of  five  wooden  baUs,  50  millimetres  in  diameter, 
painted  red,  orange,  yellow,  blue,  and  green,  respectively;  three 
wooden  pyramids;  two  wooden  parallelepipeds;  a  set  of  twelve 
cubes  varying  in  size  from  10  to  80  millimetres;  a  small  black  cube; 
test-card  of  forms;  stop-watch,  and  a  cloth  cover.  The  general 
method  of  procedure  as.  followed  by  Dr.  Goddard  consists  in  re- 
quiring the  pupil  to  select  from  a  mixed  heap  blocks  similar  to  those 
which  he  is  shown;  to  compare  those  shown  to  him  with  those  de- 
picted on  the  test-card  of  forms ;  to  denote  with  a  pointer  all  those 
on  the  test-card  which  are  similar ;  to  count  them,  and  to  compare 
their  size,  etc.  In  each  test  the  time  of  response  is  noted,  and  the 
answers  recorded  verbatim.  De  Sanctis  considers  that  they  are 
chiefly  applicable  to  children  between  seven  and  sixteen  years  of 
age,  and  claims  that,  whilst  inability  to  pass  the  two  simplest  tests 
indicates  a  high  degree  of  mental  defect,  ability  to  pass  all  six  tests 
in  normal  time  indicates  normal  intelligence. 

CASE-TAKING. 

Our  present  knowledge  of  medicine  is  largely  due  to  systematic 
case-taking,  and  our  knowledge  of  psychiatry  will  be  chiefly  ad- 
vanced by  the  same  means.  Apart  from  its  scientific  value,  how- 
ever, the  examination  of  the  mentally  deficient  involves  inquiry 
into  so  many  points  that  some  are  certain  to  be  overlooked  if 
method  is  not  employed;  whilst  the  legal  relationship  of  such  persons 
renders  it  essential  that  the  results  of  the  examination  should  be 
carefully  recorded  and  preserved.  It  follows  that  in  dealing  with 
this  class  systematic  case-taking  is  a  necessity,  and  for  this  the  first 
desideratum  is  a  suitable  form.  That  printed  on  pp.  471-474  is  a 
slight  modification  of  one  which  I  devised  some  years  ago,  and  which 
I  have  found  well  adapted  for  ordinary  cHnical  work.     It  is  printed 


Case-Taking  377 

on  a  double  sheet  of  foolscap  paper.  On  p,  i  are  given  the  name, 
address,  sex,  and  age,  of  the  patient,  the  remainder  being  left  blank 
for  photographs,  handwTiting,  etc. ;  p.  2  is  devoted  to  the  previous 
personal  and  family  histories;  p.  3  to  details  of  the  examination 
and  diagnosis;  whilst  p.  4  is  left  blank  for  remarks  as  to  the  progress 
of  the  case.  The  method  of  case-taking  will  be  best  shown  if  I 
describe  the  manner  of  filling  up  one  of  these  forms. 

A.  Previous  Personal  History. — Having  noted  the  name,  address, 
sex,  and  age,  of  the  patient,  the  first  thing  to  do  is  to  ascertain  the 
previous  personal  history  from  the  person  who  has  brought  him. 
This  should,  if  possible,  be  a  relative,  and  preferably  a  parent ;  and 
it  is  advisable  to  take  it  first,  not  only  because  it  may  afford  valu- 
able indications  as  to  the  line  of  the  future  examination,  but  because 
the  patient,  who  is  sitting  on  a  chair  in  the  room,  is  meanwhile 
growing  accustomed  to  the  examiner  and  his  surroundings,  and  will 
be  more  at  his  ease  when  such  examination  is  made.  The  first 
three  questions  call  for  no  comment,  but  they  are  very  useful,  and 
should  never  be  omitted.  Under  physiological  development  infor- 
mation should  be  noted  as  to  teething,  the  age  at  which  the  patient 
began  to  walk  alone,  to  talk,  was  clean  in  his  habits,  and  when 
puberty  appeared.  The  medical  history  includes  particulars  of  any 
serious  illnesses  or  accidents,  with  the  ages  at  which  they  occurred^ 
together  with  a  note  as  to  the  general  state  of  health — i.e.,  Has  he 
been  delicate,  or  strong  and  robust  ?  Inquiry  should  be  made  as 
to  fits,  and  if  the  child  is  alleged  to  have  received  a  head  injury, 
sufficient  details  should  be  ascertained  to  show  whether  this  was  of 
a  trivial  or  really  serious  nature.  Under  the  heading  school  history, 
note  the  age  at  commencement ;  whether  attendance  was  regular  or 
irregular;  the  kind  of  school,  whether  public  or  private,  board  or 
special;  the  age  at  leaving,  and  the  form  or  standard  attained. 
The  parent  will  often  volunteer  the  statement  that  the  subject 
could  never  learn  at  school,  or  that  constant  illness  or  errant  be- 
haviour have  stood  in  the  way  of  regular  attendance;  and  state- 
ments of  this  kind  should  be  noted.  The  general  behaviour  and 
disposition  will  be  elicited  by  running  through  the  list  given  and 
striking  out  those  which  do  not  apply.  A  record  of  the  patient's 
abilities  is  of  very  great  importance.  All  employments  that  he 
has  had  should  be  stated,  with  the  amount  of  wages  earned.  It  is 
also  valuable  to  note  the  presence  of  any  special  aptitudes  or 
tastes. 


37^  Mental  Tests  and  Case-Taking 

B.  Family  History. — The  taking  of  an  accurate  family  history  is 
a  most  difficult  and  tedious  process,  and  if  the  examiner  merely  asks 
whether  insanity,  epilepsy,  or  other  morbid  conditions  are  known 
in  the  family,  he  will  almost  certainly  be  met  by  a  prompt  and 
possibly  indignant  negative.  There  is  only  one  way  for  the  phy- 
sician to  ascertain  such  history,  and  that  is,  first  to  gain  the  confi- 
dence of  the  informant,  and  then  to  inquire  into  the  life-history  of 
every  member  of  the  family  seriatim.  If  he  has  been  tactful  and 
sympathetic  in  his  inquiries  regarding  the  condition  of  the  patient, 
the  first  point  will  probably  have  been  gained,  and  he  has  now  only 
to  proceed  systematically  from  generation  to  generation.  I  think 
it  is  better  to  begin  with  the  brothers  and  sisters  of  the  patient, 
and  my  own  rule  is  not  merely  to  record  every  live  birth,  but  every 
pregnancy,  in  the  order  in  which  it  occurred.  If  miscarriage  took 
place,  the  period  should  be  stated;  if  the  child  is  living,  a  note  should 
be  made  of  its  physical,  mental,  and  social  condition;  if  dead,  the 
age  and  cause  of  death  must  be  stated — in  fact,  the  aim  of  the 
examiner  must  be  to  obtain  as  full  details  as  possible  of  each  indi- 
vidual. In  doing  this  he  will  be  wise  to  require  facts  and  not 
opinions.  For  instance,  the  mother  may  allege  that  a  child  at 
school  is  quite  all  right,  but  further  questions  reveal  that  he  is  two 
years  behind  his  standard;  whilst  another  may  be  declared  to  be 
quite  well  and  strong,  and  yet  further  inquiry  show  that  it  is  being 
treated  for  tubercular  glands.  Having  completed  the  patient's 
brothers  and  sisters,  the  physician  then  passes  to  the  parents,  then 
to  their  brothers  and  sisters  and  their  children,  and  then  to  the 
grandparents.  Points  to  which  attention  should  be  particularly 
directed  are  the  presence  of  insanity,  epilepsy,  amentia,  marked 
eccentricity,  paralysis,  apoplexy,  crime,  pauperism,  alcoholism^ 
tuberculosis,  etc.  It  may,  of  course,  happen  that  all  these  details 
cannot  be  given  until  other  members  of  the  family  have  been  con- 
sulted, and  then  the  history  must  be  completed  on  a  subsequent 
occasion.  It  may  happen  that  they  are  unobtainable,  and  then  the 
history  must  remain  incomplete;  but,  even  so,  the  details  which 
have  been  elicited  may  be  of  considerable  value  in  the  diagnosis 
of  that  particular  case,  although  they  may  be  incapable  of  use  for 
statistical  purposes. 

C.  Present  Condition. — Under  the  heading  general  appearance, 
it  is  very  useful  to  note,  in  a  short,  concise  sentence,  the  chief 
features  of  the  patient  as  they  strike  the  physician.     Thus,  such. 


Case-Taking  379 

statements  as,  "An  ill-developed,  tmgainly  youth,  ivith  a  scowling, 
furtive  expression  and  restless  habits";  or  "A  short,  fat,  smiling 
young  woman  of  childish  expression  and  linconcerned  demeanour  " ;  or 
"  A  boy  of  twelve  years,  hut  only  looking  eight,  cannot  sit  or  stand 
still,  constantly  chattering  and  grimacing,"  give  a  general  impression 
of  the  case,  which  not  only  help  to  recall  it,  but  which  may  be  of 
considerable  value.  Under  physical  condition  must  be  noted 
height,  weight,  general  development  and  nutrition,  skull  measure- 
ments (the  method  of  taking  these  has  been  described  on  p.  139), 
the  presence  of  developmental  anomalies  and  stigmata  of  de- 
generacy, and  any  signs  of  ill-health  or  disease.  The  physician 
next  proceeds  to  the  mental  examination.  If  time  permits,  he  may 
apply  seriatim  the  "  mental  tests  "  which  have  been  described  in 
the  preceding  section;  but  if  more  experienced,  he  will  usually 
derive  information  of  equal  value  by  the  simpler  methods  of 
examining  the  patient's  range  of  information  and  his  ability  to 
reconstruct  dissected  pictures  in  the  manner  already  referred  to. 
Any  special  defect  which  is  thus  revealed  may  then  be  further 
examined  by  the  appropriate  psychological  test.  The  results  are 
recorded  under  each  heading  with  the  signs  +  (in  excess),  -  (in 
defect),  O  (normal);  but  a  statement  should  always  be  made  as  to 
the  test  used,  and  what  the  patient  actually  does.  For  example, 
under  the  heading  attention  would  be  noted:  "  ( — ),  played  with 
picture  squares  for  a  few  seconds,  and  then  went  to  look  out  of 
window,  then  picked  up  ball  from  floor,  threw  it  away,  and 
snatched  book  from  table."  Many  of  the  patient's  capabilities  will 
have  become  evident  from  the  mental  examination — for  instance, 
his  abilit}'  to  read,  write,  and  sum;  but  it  is  useful  to  tabulate  these 
separately,  and  to  include  a  note  as  to  his  general  capacity  for 
occupation  and  employment.  Information  on  this  point  may  have 
to  be  obtained  from  external  sources,  but  it  is  often  a  very  good 
plan  to  get  the  patient  to  describe  in  detail  how  he  would  set  about 
doing  some  particular  task  of  which  he  is  said  to  be  capable. 
Finally,  the  diagnosis  arrived  at  is  entered.  If  the  patient  is  an 
ament,  the  degree  should  be  stated,  together  with  a  short  statement 
of  the  evidence  upon  which  the  classification  is  made. 


CHAPTER  XVIII 

DIAGNOSIS  AND  PROGNOSIS 

In  view  of  the  legal  status  of  persons  suffering  from  mental 
defect,  the  diagnosis  of  this  condition  is  probably  the  most  im- 
portant, and  in  some  instances  may  certainly  be  the  most  difficult 
matter  which  the  practitioner  is  caUed  upon  to  undertake  in  regard- 
to  this  class.  In  many  cases  it  may  be  his  only  duty,  since  care 
and  treatment  will  usually  be  relegated  to  the  medical  officers  in 
charge  of  schools,  homes,  and  institutions  specially  adapted  for 
this  purpose.  In  other  cases,  however,  particularly  children,  his 
duties  may  embrace  a  wider  scope,  and  he  may  then  be  expected 
to  answer  three  questions :  Firstly,  Is  amentia  really  present  ? 
Secondly,  To  what  extent  can  it  be  improved  ?  Thirdly,  What  is 
the  form  of  treatment  to  be  adopted  ?  These  three  matters  of 
diagnosis,  prognosis,  and  treatment  will  be  dealt  vith  in  the  present 
and  succeeding  chapters. 

DIAGNOSIS. 

The  diagnosis  of  amentia  may  most  usefully  be  considered  at 
three  periods — namely,  during  infancy,  childhood,  and  adult  life. 
At  each  of  these  stages  there  are  conditions  ^^ith  which  mental 
defect  is  more  particularly  liable  to  be  confused,  and  from  which, 
it  has  to  be  differentiated. 

Diagnosis  in  Infancy  and  Early  Childhood. 

In  infants  the  symptom  which  usually  first  attracts  attention, 
and  which  causes  the  parents  to  seek  advice,  is  the  presence  of 
abnormal  nerve  signs.  Briefly,  there  is  either  a  state  of  torpid, 
listless  indifference,  so  that  the  child  makes  no  attempt  to  suck,  does 
not  look  about  him,  does  not  cry,  and,  in  fact,  is  generally  lacking 

3S0 


Diagnosis  in  Infancy  and  Early   Childhood      381 

in  spontaneitj' ;  or  the  reverse  of  this  condition  is  present,  the  child 
being  abnormally  restless,  always  crying  and  tossing  about,  and 
getting  hardly  any  sleep.  In  cases  of  severe  amentia,  one  or 
other  of  these  states  is  generally  present  during  the  first  twelve 
months.  The  latter,  however,  attracts  most  attention,  for  mothers 
are  incHned  to  look  upon  the  former  as  merely  an  excessive 
amount  of  "  goodness,"  and,  at  first,  to  congratulate  themselves 
accordingly. 

But  these  conditions,  although  abnormal  and  indicative  of  brain 
disturbance  of  some  kind,  are  not  diagnostic  of  amentia.  They  may 
result  from  inadequate  or  improper  feeding,  causing  general  malnutri- 
tion, or  from  some  more  serious  bodily  disease.  The  first  care  of  the 
physician,  therefore,  must  be  to  make  a  thorough  physical  examina- 
tion of  the  child,  and  particularly  to  exclude  such  morbid  states  as 
anaemia,  rickets,  malnutrition,  bone  caries,  the  various  forms  of 
tuberculosis,  otitis,  meningitis,  cerebral  abscess,  and  reflex  causes 
of  nervous  irritation. 

Having  done  this  and  ascertained  that  there  is  no  bodily  condition 
responsible  for  the  nervous  abnormality,  he  has  still  to  decide 
whether  he  is  dealing  with  a  child  preternaturally  dull  and  stolid, 
with  one  unduly  excitable  and  neurotic,  or  with  one  who  is  really 
mentally  deficient.  Here  the  family  history  and  the  presence  of 
stigmata  of  degeneracy  or  features  peculiar  to  certain  varieties  of 
amentia  will  be  of  great  value. 

If  with  either  of  these  abnormal  nervous  states  there  is  associated 
a  pronounced  morbid  heredity,  there  is  a  strong  probability  that 
the  child  will  turn  out  to  be  mentally  deficient.  If  stigmata  of 
degeneracy  are  present  in  addition,  this  probability  is  greatly 
increased,  and  a  diagnosis  may  thus  be  possible  in  the  early  months 
of  life.  If  special  features  exist,  such  as  the  abnormally  small 
skull  of  the  microcephalic,  the  peculiar  physiognomy  of  the  Mongol 
or  cretin,  the  changes  in  the  fundus  of  infantile  cerebral  degenera- 
tion, or  even  marked  paralysis,  the  diagnosis  may  be  made  with 
certainty. 

But  even  if  stigmata  be  absent,  and  the  child's  condition  be  plainly 
due  to  brain  disease  without  neuropathic  predisposition,  it  must 
still  be  remembered  that  serious  disease  of  the  brain  occurring  in 
early  life  may  give  rise  to  secondary  amentia,  if  death  does  not 
previously  end  the  scene;  whilst  this  possibility  is  greatlj^  increased 
by  the  presence  of  morbid  heredity.     The  association  of  continuous 


382  Diagnosis  and  Prognosis 

epileptic  convulsions  with  any  of  these  conditions  greatly  adds  to 
the  unfavourable  outlook  as  to  the  future  mental  development. 

In  cases  seen  somewhat  later— say  during  the  third  or  fourth 
year — there  is  less  difficulty  in  arriving  at  a  diagnosis.  Not  only 
is  there  the  great  advantage  of  a  longer  life-history,  and  conse- 
quently more  information  forthcoming  as  to  general  behaviour; 
but,  since  by  the  age  of  three  or  four  years  the  normal  child  has 
made  considerable  intellectual  advance,  the  arrears  of  the  mentally 
deficient  one  at  this  age  are  by  contrast  much  more  apparent. 
Dr.  Ashby  says  that,  provided  there  is  no  auditory  defect,  marked 
slurring  or  baby  language  in  a  child  of  five  or  six  years  is  almost 
always  associated  with  subnormal  intelligence.  Idiocy,  imbecility, 
and  pronounced  feeble-mindedness  can  now  hardly  fail  to  be 
detected,  and  the  only  difficulty  experienced  wiU  be  with  regard 
to  the  mildest  degrees  of  intellectual  or  moral  defect.  It  is  stiU 
necessary  to  remember,  however,  that  amentia  may  be  simulated 
by  bodily  ill-health  or  disease,  as  well  as  by  delayed  development 
or  dullness  of  intellect  not  amounting  to  defect. 

Diagnosis  during  Later  Childhood  and  School  Age. 

The  conditions  which  usuaUy  give  rise  to  a  question  of  possible 
mental  defect  at  this  age  are  either  inability  to  learn  at  school  or 
marked  perversity  of  conduct;  very  often  the  two  are  associated. 
The  condition  with  which  amentia  is  most  readily  confused  is 
scholastic  backwardness  due  to  causes  other  than  defect.  This 
backwardness,  or  mental  retardation,  is  such  a  frequent  and  im- 
portant occurrence  among  school-children  that  it  is  necessary  to 
give  an  account  of  it  before  considering  the  question  of  a  differ- 
ential diagnosis.  It  may  be  remarked  that  parents  not  infrequently 
resent  a  diagnosis  of  mental  defect,  and  in  the  case  of  children 
attending  a  public  elementary  school  it  has  sometimes  happened 
that  the  school  medical  officer  has  been  called  into  court  to  convince 
a  magistrate  of  the  accuracy  of  his  diagnosis  before  the  child's 
attendance  at  a  special  school  could  be  enforced,  and  the  diagnosis 
of  defect  has  not  always  been  sustained. 

Mental  Retardation. — Backwardness  in  mental  development  ma3- 
be  noticed  long  before  school  age;  but  since  it  is  usually  in  school- 
children that  it  first  begins  to  attract  serious  notice,  and  to  become 
a  problem  of  practical  importance,  it  is  during  this  age  that 
we   shall   consider   it.     Children   attending   school    (excluding   the 


Diagnosis  during  School  Age  383 

mentally  deficient)  may  be  divided  into  four  classes — namely, 
bright,  fair,  dull,  and  backward.  These  terms  are  used  with  refer- 
ence to  their  general  ability  in  the  ordinary  school  work;  thus, 
"  bright  "  children  are  those  who  master  the  lessons  prescribed  by 
the  curriculum  for  their  age  and  form  or  standard  with  ease;  the 
"fair"  are  the  ordinary  average  members  of  the  class;  "dull" 
children  are  those  who  keep  their  place  in  the  standard,  but  do  so 
with  difficulty;  whilst  "  backward  "  children  are  those  who  are 
behind  the  average  standard  for  their  years.  The  relative  pro- 
portions of  these  classes  vary  greatly  in  different  localities,  and  the 
absence  of  any  definite  standard  of  comparison,  together  with  the 
number  of  personal  equations  involved,  render  official  figures  of 
little  value  as  an  indication  of  their  incidence.  Probably,  however, 
we  shall  not  be  far  wrong  in  stating  that  the  dull  and  backward 
groups  together  comprise  about  10  per  cent,  of  the  public  elementary 
school  population  of  the  country,  this  proportion  varying  from  a 
minimum  of  5  per  cent,  to  a  maximum  of  15  to  20  per  cent,  in 
different  situations.*  It  is  an  interesting  fact  that  the  proportion 
of  backward  boys  is  higher  than  is  that  of  girls. 

Dull  and  backward  children,  therefore,  compose  a  very  con- 
siderable section  of  the  school  population,  and  they  form  that 
class  in  whom  mental  development,  from  the  scholastic  standpoint, 
may  be  looked  upon  as  retarded  or  defective.  But  closer  inquiry 
shows  that  the  class  is  in  realit}^  a  verj^  heterogeneous  one,  and  m}^ 
observations  of  a  very  large  number  of  these  children  have  caused 
me  to  divide  them  into  two  chief  groups,  according  as  to  whether 
the  backwardness  is  the  result  of  innate  or  acquired  conditions. 
These  may  briefly  be  referred  to. 

Group  I — Innate  Dtdlness. — These  children  are  usually  sturdy, 
well  grown,  and  in  good  physical  health ;  but  they  have  no  capacity 
for  book-learning,  and  the  teacher  finds  the  greatest  difficulty  in 
teaching  them  the  most  elementary  abstract  rules.  Occasionally 
they  may  shine  in  some  one  particular  subject,  but  this  is  except 

*  In  Somersetshire,  in  1905,  I  found  the  ratio  of  dull  and  backward  children 
varied  from  5  to  20  per  cent,  of  the  school  population  in  different  localities. 

Dr.  Duncan  Forbes  found  that  of  6,318  school-children  at  Brighton  in  1912 
the  proportions  were  as  follows  (both  sexes):  Bright,  55-5  per  cent.;  fair, 
34  per  cent.;  dull,  S-i  per  cent.;  backward,  2-2  per  cent. 

Dr.  Goddard  found  that  of  2,000  American  school-children  whom  he  investi- 
gated 78  per  cent,  were  "  normal,"  4  per  cent,  were  gifted  beyond  the  normal, 
15  per  cent,  were  backward,  and  3  per  cent,  were  mentally  defective. 

Pedagogical  Seminary,  June,  1911. 


384  Diagnosis  and  Prognosis 

tional,  and  in  most  instances  there  is  the  greatest  distaste  and 
inability  for  all  kinds  of  school  work.  They  are  the  children  who, 
in  former  years,  spent  most  of  their  time  in  a  corner  of  the  class- 
room, decorated  with  a  sugar-loaf  cap  and  a  slate,  on  which  was  in- 
scribed the  word  "  Dunce."  In  my  experience  they  are  commoner 
in  country  villages  than  in  towns,  and  they  are  often  the  descendants 
of  generations  of  agricultural  labourers,  who  have  done  excellent 
work  with  their  hands,  but  very  little  with  their  heads.  I  have 
seen  instances  where  children,  parents,  uncles,  and  aunts  all  be- 
longed to  the  same  type,  and  there  is  no  doubt  that  in  very  many 
cases  the  failing  is  a  family  one — it  is,  in  fact,  inherited. 

During  a  conversation  on  this  subject  which  I  had  with  an 
intelligent  old  dominie  of  a  country  school,  he  produced  an  excellent 
example  in  three  members  of  one  family  who  were  present  in  school 
at  that  time,  and  who  were  such  hopeless  dunces  that  their  attend- 
ance seemed  a  complete  waste  of  time.  My  informant  told  me  that 
the  father  of  these  children,  and  his  brothers  and  sisters,  had  all 
been  through  his  hands  in  their  turn,  and  they  were  just  the  same; 
but  although  the  father  could  only  manage  to  scrawl  his  name, 
and  could  not  read  the  newspaper,  he  nevertheless  worked  a  small 
farm  with  complete  success.  Children  of  this  kind  occur  in  the 
towns  also,  and  although  they  cannot  or  will  not  (I  think  it  is  a 
little  of  both)  make  any  headway  with  their  lessons,  they  are  as 
sharp  as  needles  on  the  playground  and  in  the  streets. 

As  further  examples  of  this  form  of  school  backwardness,  I  may 
mention  the  case  of  two  brothers,  aged  ten  and  twelve  respectively, 
who,  during  my  examination  of  a  large  country  school,  were  pro- 
duced by  their  teacher  as  being  very  bad  cases  of  mental  deficiency. 
They  were  both  in  Standard  II.,  and  my  examination  showed  that 
they  were  certainly  unequal  to  the  work.  But  I  soon  found  that 
they  had  a  very  good  knowledge  of  many  details  of  country  and 
farm  life — of  the  cows,  the  corn,  and  the  bird-nesting — and  that 
ihey  were  by  no  means  backward  in  the  playground.  In  fact,  I 
had  little  difficulty  in  demonstrating  to  the  teacher  that,  although 
these  boys  could  hardly  do  the  simplest  sum,  and  could  only  read 
and  write  words  of  one  syllable,  yet  they  had  plentj^  of  common 
sense,  and  were  by  no  means  mentally  deficient. 

Another  child  of  this  kind  whom  I  recently  saw,  a  girl,  aged 
twelve  years,  who,  on  account  of  her  age  and  size,  had  been  moved 
up  to  Standard  V.,  told  me  that  David  was  the  son  of  Goliath,  and 


Diagnosis  during  School  Age  385 

that  he  married  Rebekah.  She  could  give  me  no  information 
about  India,  except  that  it  was  a  country  somewhere.  She  could 
write  a  passable  hand,  but  her  spelling  was  bad,  and  her  arithmetic 
execrable.  And  yet  she  was  by  no  means  a  fool  in  other  matters. 
She  could  clean  out  a  room,  could  wash  and  dress  the  younger 
children,  and  could  cook  the  dinner  with  very  little  help.  I  have 
small  doubt  that,  unless  her  father  apprentices  her  to  a  dress- 
maker or  a  typewriting  agency,  or  some  other  superior  employment 
now  in  vogue  for  "  young  ladies,"  for  which  she  is  quite  unsuited, 
she  would  make  an  excellent  domestic  servant. 

It  is  possible  that  some  observers  would  consider  this  condition 
to  be  one  of  mild,  but  none  the  less  real,  mental  defect.  I  do 
not  think,  however,  that  such  persons  should  be  so  classed.  Their 
family  history  is  generally  good;  they  are  sturdy,  weU  grown,  free 
from  stigmata  of  degeneracy,  and  fully  up  to  the  average  in  every 
iaculty  except  ability  to  acquire  book-learning.  It  seems  to  me 
that  they  are  perfectly  normal,  and  not  diseased  specimens  of  man- 
kind, and  that  their  condition  is  simply  one  of  a  somewhat  tardy 
evolution  of  certain  faculties,  the  result  of  the  manner  of  life  of 
generations  of  ancestors.  The  term  "  mental  deficiency,"  in  my 
opinion,  should  be  restricted  to  those  persons  who  are  so  lacking 
in  general  mental  capacity,  in  common  sense,  that  they  are  in- 
capable of  subsisting  by  their  own  unaided  efforts.  No  doubt  book- 
learning  is  a  valuable  asset  under  present-day  conditions,  but  it 
is  not  essential,  and  there  are  very  many  individuals  who,  although 
scholastically  dunces,  have  yet  sufficient  aptitudes  of  other  kinds, 
and,  in  particular,  sufficient  common  sense,  not  only  to  take  care 
of  their  interests,  but  to  achieve  a  considerable  degree  of  success 
in  a  humbler  walk  of  life. 

The  conditions  of  word-blindness  and  word-deafness,  which  have 
been  described  on  p.  134,  may  also  be  placed  in  this  categor}'  of 
school  backwardness  due  to  innate  causes.  It  is  also  necessary 
to  remember  that  a  number  of  children  exist  who  mature  later  than 
do  the  average,  and  who,  on  that  account,  may  be  thought  to  be 
defective.  Several  men  who  have  subsequently  attained  to  con- 
siderable eminence  have  been  of  this  type. 

Group  II — Acquired  Dullness. — The  children  in  this  group  differ 
from  those  in  the  preceding,  in  that  their  innate  potentiality  for 
school  work  is  good;  but  their  mental  development  has  been  hin- 
dered, and  a  varying  degree  of  dullness  and  backwardness  pro- 

25 


386  Diagnosis  and  Prognosis 

duced  by  malnutrition,  illness,  or  disease.  Unlike  the  former,  the 
condition  is  much  commoner  in  our  large  towns  than  in  the  country, 
and  it  often  simulates  real  amentia  so  closely  that  for  a  time  a 
diagnosis  may  be  impossible. 

It  has  alread}^  been  stated  that  certain  factors  of  the  environ- 
ment may  possibly,  but  very  occasionally,  produce  mental  defect. 
More  commonly,  however,  the  insufficient  and  improper  feeding, 
the  absence  of  fresh  air  or  warmth,  and  the  general  neglect  which 
unfortunately  attaches  to  the  early  life  of  many  of  the  children  in 
our  densely  populated  industrial  centres,  produce  a  retardation 
of  mental  growth  which  is  not  permanent,  and  is  not  therefore 
amentia.  In  real  amentia  there  is  either  an  actual  and  permanent 
arrest  or  an  incapacity  for  perfect  development,  o^^ing  to  a  blight 
of  the  seed.  In  these  cases  it  is  the  soil  which  is  unsatisfactory, 
and  the  condition  may  not  inaptly  be  compared  to  the  late  opening 
of  the  flower-buds  in  consequence  of  chiU  winds  and  absent  sun. 
It  is  what  may  be  described  as  a  late  spring,  and  the  characteristic 
of  these  cases  is  that  under  more  congenial  surroundings  the 
brain  rapidly  recovers,  and  the  child  soon  regains  the  normal 
standard.  It  may  be  several  years  before  this  change  takes  place, 
and  it  often  does  so  with  surprising  suddenness;  so  that  the  child 
who  has  hitherto  been  dull,  vacant,  and  apparently  suffering  from 
undoubted  mental  deficiency,  astonishes  everybod}^  by  suddenly 
waking  up. 

In  other  instances  the  same  result  is  brought  about  by  illness  or 
disease  of  a  more  definite  and  tangible  character.  The  chief 
morbid  conditions  which  may  thus  produce  a  mental  hebetude 
simulating  defect  are  anaemia,  tuberculosis,  adenoids  and  enlarged 
tonsils,  defective  vision,  and  deafness;  and  a  child  so  suffering  may 
rapidly  fall  behind  those  of  his  age  in  school  work.  Under  the 
present  system  of  medical  inspection  the  cause  of  such  backward- 
ness is  not  very  hkely  to  be  overlooked,  but  school  teachers  may 
readily  fall  into  error,  and  I  have  had  boys  and  girls  produced  as 
cases  of  serious  defect  who  merely  wanted  the  attention  of  the- 
oculist  or  nose  and  throat  specialist,  or  who  h.d,ve  been  suffering 
from  pulmonary  tuberculosis.  At  the  same  time  the  presence  of 
disease  of  this  kind  does  not,  of  course,  negative  mental  defect. 

Another  condition,  not  uncommonly  seen  in  the  consulting- 
room,  which  may  give  rise  to  a  suspicion  of  amentia,  is  that  of. 
nervous  exhaustion.     The  child  is  dull,  listless,   and  inattentive^ 


Diagnosis  during  School  Age  387 

He  cannot  be  got  to  answer  questions,  and  if  given  a  simple  sum  he 
does  it  wrong.  His  co-ordination  is  imperfect,  his  memory  is 
fault^^  there  is  often  tremor,  his  head  may  be  small  and  asym- 
metrical, and  his  lower  eyelids  are  baggy  and  relaxed.  The  history 
will  generally  show  that  the  mental  hebetude  is  of  recent  origin, 
and  that  previously  the  child  has  been  of  ordinary,  sometimes 
unusual,  brightness;  but  as  against  this  the  inquirer  may  elicit  a 
neuropathic  family  history.  The  condition  here  is  probably  one 
of  neurasthenia  in  a  child  with  but  a  small  reserve  of  nerve  force. 
It  is  often  accompanied  by  severe  headache,  and  is  usually  the 
result  of  overpressure.  These  children  form  the  class  from  which 
a  considerable'  proportion  of  the  insane  population  is  drawn,  and 
although  most  cases  recover  under  suitable  treatment,  the  dullness 
of  mind  occasionally  persists  until  the  child  becomes  a  complete 
mental  wreck.  In  older  children  this  state  may  owe,  its  origin  to 
masturbation.  Epilepsy,  also,  may  give  rise  to  a  very  consider- 
able degree  of  backwardness  in  school  work,  and  this  may  escape 
detection  for  some  time,  owing  to  the  fits  being  nocturnal  and  un- 
known to  the  parents.  The  presence  of  loss  of  memory,  with 
alternating  brightness  and  stupidity,  is  very  suggestive,  and  the 
probability  is  further  increased  if  there  is  a  history  of  bed- wetting; 
but  it  is  only  by  continuous  observation  of  the  child  at  night  that 
the  cause  can  be  discovered  with  certainty.  Here,  again,  it  is 
necessary  to  remember  that  epilepsy  and  mental  defect  may,  and 
frequently  do,  coexist,  and  that,  even  if  no  amentia  is  present,  it 
is  very  likely  that  dementia  will  supervene. 

Insanity  might  possibly  be  confused  with  mental  defect,  but  the 
relative  rarity  of  this  condition,  and  the  usually  evident  fact  that 
the  child  is  suffering  from  a  disorder,  and  not  an  arrest  of  mind, 
ought  to  prevent  such  a  mistake. 

The  diagnosis  of  mental  defect   from  the  conditions  we  have 
just  described  must  be  made  from  a-  careful  study  of — (i)  The 
previous  pejrsonal  history  of  the  child;  (2)  the  family  history;  and. 
(3)  his  present  physical  and  mental  condition. 

In  investigating  the  personal  history,  inquiry  must  first  be  made 
as  to  whether  the  backwardness  can  be  accounted  for  by  late  com- 
mencement or  irregular  attendance  at  school.  If  the  child  started 
at  the  usual  time,  has  attended  regularly,  and  his^general  conduct 
has  been  good,  it  follows  that  the  backwardness  must  either  be 


388  Diagnosis  and  Prognosis 

the  result  of  innate  or  acquired  dullness  or  of  mental  defect,  and 
the  next  point  is  to  ascertain  whether  it  is  of  recent  or  long  standing. 
If  recent,  it  will,  in  all  probability,  be  found  to  belong  to  the  class 
of  acquired  dullness  due  to  ill-health  or  disease;  although  it  is 
necessary  to  remember  that  some  cases  of  primary  amentia  (de 
layed  or  developmental  amentia)  do  not  become  sufficiently  pro- 
nounced to  attract  attention  until  the  advent  of  some  comparatively 
slight  illness  or  mental  stress,  and  school  work  may  supply  this 
stress.  It  may  also  happen  that  the  case  is  one  of  secondary 
amentia,  due  to  some  serious  toxic  or  vascular  lesion  of  the  brain, 
but  of  such  occurrences  there  will  usually  be  a  clear  and  definite 
history.  If  the  backwardness  is  not  due  to  any  of  these  causes, 
the  condition  may  be  one  of  innate  dullness  or  of  mental  defect. 

In  most  cases  of  primary  amentia  it  will  be  found  that  some 
dullness  or  peculiarity  has  been  noticed  from  infancy,  and  a  careful 
inquiry  into  the  life-history  of  the  child  will  usually  show  that 
there  has  been  a  general  retardation  of  physiological  development, 
such  as  lateness  in  cutting  his  teeth,  in  sitting  up,  in  attempting 
to  stand,  to  walk,  and  to  talk  (see  table  of  normal  developmental 
data,  p.  466).  Delay  in  any  one  of  these  particulars  is  of  little 
importance,  for  the  range  of  normal  variation  is  very  considerable; 
but  delay  in  several  particulars,  provided  there  is  an  absence  of 
bodily  disease,  such  as  rickets,  etc.,  must  be  regarded  as  very  sus- 
picious, especially  if  accompanied  by  a  neuropathic  family  history. 
On  the  other  hand,  the  child  whose  backwardness  in  school  is  not 
due  to  mental  deficiency,  but  merely  to  the  innate  dullness  for 
scholastic  work  which  I  have  described,  will  usually  be  found  to 
show  none  of  these  features  of  retarded  physiological  development. 

The  next  matter  to  inquire  into  is  the  family  history.  In  many 
instances  it  may  be  impossible  to  elicit  more  than  the  most,  frag- 
mentary account,  but  where  a  tolerably  good  history  is  obtainable, 
it  may  be  of  the  greatest  value  in  helping  the  physician  to  arrive 
at  a  diagnosis.  In  secondary  amentia  there  is  no  neuropathic 
inheritance ;  such  cases,  however,  will  be  made  clear  by  the  previous 
personal  history.  On  the  other  hand,  a  family  history  of  insanity, 
epilepsy,  amentia,  or  other  neuropathic  state,  occurs  in  such  a  large 
proportion  of  primary  aments  that  their  presence  or  absence  is 
an  indication  not  to  be  neglected. 

The  third  point  to  be  considered  is  that  of  the  child's  present 
condition.      The  methods  of  examining  and  recording  this  have 


Diagnosis  during  School  Age  389 

already  been  described,  and  the  question  now  before  us  is  as  to 
the  inference  to  be  drawn  from  the  results  so  obtained.  At  this 
point  I  would  again  warn  the  physician  against  looking  upon 
psychological  tests  as  automatic  registers  of  the  presence  or  absence 
of  mental  defect.  Rightly  used  and  interpreted,  they  are  of  the 
greatest  value.  They  may  show  that  the  child  is  not  up  to  the 
usual  standard  for  his  age  in  respect  of  certain  mental  processes; 
they  may  reveal  the  presence,  not  of  a  general  backwardness  of 
development,  but  of  a  marked  inferiority  in  respect  of  certain 
particular  mental  functions,  and  thus  show  that  the  child's  mental 
development  is  irregular;  and  this,  to  my  mind,  is  a  still  more 
important  indication.  But  the  physician  must  know  how  to 
interpret  these  tests,  and  he  must  also  carefully  consider  the  family 
and  personal  history  if  he  would  arrive  at  a  true  conclusion  as  to 
the  child's  innate  potentiality  for  development  and  the  presence 
or  absence  of  mental  deficiency. 

In  children  of  school  age  the  diagnosis  of  mental  defect  cannot 
always  be  made  with  certainty,  and,  as  a  matter  of  fact,  the  return 
of  a  considerable  proportion  of  certified  "  mentally  defective " 
children  from  the  special  to  the  ordinary  schools  shows  very  clearly 
that  errors  are  frequently  made.  Diagnosis,  in  fact,  is  an  art 
which  cannot  be  taught,  but  only  acquired  by  experience  and  close 
observation  of  mentally  defective  persons,  and  the  physician  who 
has  the  largest  experience,  the  keenest  powers  of  observation,  and 
the  best  judgment,  will  be  the  one  whose  inferences  are  more  often 
correct,  and  whose  mistakes  are  fewest. 

The  important  point  for  diagnostic  purposes,  therefore,  is  to 
know  what  inferences  may  be  drawn  from  the  facts  disclosed  by 
examination  of  the  patient.  With  regard  to  the  child's  physical 
condition,  if  he  is  suffering  from  deafness,  errors  of  refraction, 
adenoids,  marked  anaemia,  malnutrition,  or  other  serious  disturb- 
ance of  the  general  health,  and  if  with  this  the  previous  history 
shows  no  general  physiological  retardation  and  the  family  history 
no  marked  neuropathic  inheritance,  it  is  a  justifiable  inference  that 
his  mental  dullness  is  caused  by  his  bodily  condition,  and  is  not  due 
to  a  fundamental  incapacity  for  development.  It  is  true,  as  I  have 
already  pointed  out,  that  bodily  disease  does  not  negative  m^ental 
defect;  but  if  this  latter  be  present,  there  will  usually  be  some 
indication  under  the  two  other  headings  mentioned. 

On  the  other  hand,  if  the  child's  physical  condition  is  good,  his 


390  Diagnosis  and  Prognosis 

mental  reactions  must  then  be  closely  scrutinized,  with  a  view  to 
ascertaining  whether  there  is  anything  which  would  indicate  gross 
irregularity  of  mental  evolution  or  subnormal  potentiality  for 
development.  These  two  conditions  constitute  the  essential 
characteristics  of  the  defective  mind,  and  if  they  are  present, 
the  inference  is  justified  that  some  cause  is  at  work  militating 
against  complete  mental  evolution.  If  defects  are  revealed  in 
the  family  and  previous  life-history,  the  inference  becomes  a 
tolerable  certainty. 

Irregularity  of,  and  diminished  potentiality  for,  mental  develop- 
ment may  be  shown  in  many  ways.     In  one  child  it  may  happen 
that,  although  the  application  of  tests  reveals  a  power  of  judgment 
greatly  inferior  to  that  of  the  average  child  of  similar  age,  together 
with,  it  may  be,  a  defective  association,  poor  attention,  and  but 
little  memory  for  a  sequence  of  events,  the  child  can  yet  hum  a 
tune  which  he  has  only  once  heard,  repeat  rhymes,  or  remember 
particular    dates    and    isolated    occurrences,    with    extraordinary 
fidelity.     Another  child,   whilst  regarded  by  his  teacher  as  dull, 
may  do  a  passable  examination  paper  on  facts  which  have  been 
dinned  into  him,  he  may  even  shine  in  some  one  subject,  such  as 
history;  but  he  is  quite  unable  to  put  together  a  dissected  picture 
in  its  proper  order  owing  to  defective  judgment.     In  all  cases  of 
this  kind  we  have  evidence  that  the  backwardness  is  accompanied 
by  marked  irregularity,   and  that  the  developmental  potentiality 
of  certain  portions  of  the  brain  is  subnormal.     It  is  only  by  his 
clinical  experience,  acuteness  of  observation,  and  powers  of  deduc- 
tion, that  the  physician  will  be   enabled   to   decide   whether   the 
imperfection  is  of  such  a  quality  and  quantity  as  is  likely  to  prevent 
the  child  when  grown  up  from  so  adjusting  his  conduct  and  mode 
of  life  to  his  environment  as  to  be  capable  of  maintaining  an  exist 
ence  without  supervision.     It  was  said,   "  He  that  is  faithful  in 
that  which  is  least  is  faithful  also  in  much,"   and  although  the 
nature  of  the  adaptation  required  of  the  child  is  very  different 
to  that  required  of  the  adult,  it  is  improbable  that  a  child  who  is 
so  lacking  in  common  sense  and  general  intelligence  as  to  be  unable 
to  hold  his  own  amidst  any  of  the  interests  of  childhood  will  develop 
that  ability  when  adult  life  is  reached. 

Mentally  Defective  Children  and  Imheciles.-^Hzxing  come  to  the 
conclusion  that  the  mental  condition  of  the  child  under  examination 
is  not  due  to  disease  or  ill-health,  is  not  merely  "  dullness  and  back- 


Diagnosis  during  Adolescence  and  Adult  Life     391 

wardness,"  but  is  one  of  deficiency,  the  physician  who  is  examining 
for  the  purpose  of  certification  to  a  special  school  will  be  required 
to  exclude  imbecility.  In  pronounced  cases  of  this  latter  there  will 
be  no  difficulty,  but  in  the  milder  degrees  a  differential  diagnosis 
will  be  far  from  easy.  The  following  points  may  be  found  of 
assistance : 

As  a  rule  the  mentally  defective  school-child  knows  the  names 
of  common  objects,  and  can  give  some  account  of  their  use,  whilst 
the  imbecile  of  corresponding  age  is  generally  lacking  in  tliis  know- 
ledge. Neither  child  may  know  his  letters,  but  the  mentally 
defective  will  usually  recognize  and  name  various  articles 
shown  to  him  in  pictures.  Speech  is  often  a  valuable  indication, 
although  it  is  to  be  remembered  that  many  merely  feeble-minded 
children  speak  exceedingly  badly.  It  is  rather  the  matter  than  the 
manner  of  speech  which  must  be  attended  to,  as  showing  the  degree 
of  general  intelligence.  Some  imbeciles  will  repeat  questions; 
others  obviously  fail  to  understand  what  is  said  to  them;  other* 
ramble  on  in  an  utterly  nonsensical  manner,  and  are  quite  incapable 
of  carrying  on  the  simplest  conversation.  The  inabihty  to  execute 
some  simple  command  or  the  manner  of  doing  so  often  affords  most 
useful  information.  Above  all,  however,  the  imbecile  is  markedly 
deficient  in  common  sense.  He  can  rarely  be  depended  upon  to 
perform  any  simple  errand  or  task  unless  watched  the  whole  time, 
and  he  will  often  sit  outside  in  the  rain  and  get  wet  through  without 
making  the  slightest  effort  to  shelter. 

Diagnosis  during  Adolescence  and  Adult  Life. 

The  diagnosis  at  these  ages  is  usually  a  matter  of  less  difficulty 
for  the  reason  that  a  longer  life-history  is  available,  which  will 
supply  important  information  as  to  the  person's  actual  capacity 
in  the  management  of  his  affairs  and  of  his  general  competence  to 
exist  without  supervision.  Among  the  wealthy  classes,  or  where 
property  is  concerned,  such  cases  may  form  the  subject  of  a  legal 
inquiry,  and  the  greatest  care  must  be  taken  in  arriving  at  and 
stating  an  opinion.  This  also  now  applies  to  persons  coming 
within  any  of  the  six  categories  of  Clause  2  of  the  Mental  Deficiency 
Act  who  may  require  to  be  examined  for  certification  and  detention 
in  an  institution. 

The  question  of  the  diagnosis  of  idiocy  and  imbecility  needs  no 
comment,  for  it  will  readily  be  made  from  the  description  of  these 


392  Diagnosis  and  Prognosis 

states  which  has  been  given  in  preceding  chapters.  Practically 
the  only  difficulty  will  be  in  regard  to  cases  of  the  feeble-minded 
degree  of  defect  and  of  moral  imbecility.  These  we  shall  now 
consider. 

The  feeble-minded  adolescent  or  adult  has  to  be  differentiated 
from  the  lowest  grade  of  the  "  normal  "  population,  and  from 
certain  forms  of  mental  perversion  or  dissolution.  With  regard  tO' 
the  lowest  intellectual  stratum  of  the  normal  class,  there  is  nO' 
doubt  that,  in  spite  of  the  money  and  time  spent  upon  their  edu- 
cation, a  very  large  number  of  persons  exist  whose  scholastic 
acquirements  are  of  the  most  limited  description,  whose  powers  of 
comprehension  are  small,  and  whose  reasoning  capacity  is  of  a 
very  low  order.  They  are  the  hewers  of  wood  and  the  drawers 
of  water,  and  even  these  simple  tasks  are  at  times  not  over-well 
performed.  Nevertheless,  they  stand  widely  removed  from  the 
feeble-minded  in  that  they  possess  sufficient  of  the  saving  grace  of 
common  sense  to  look  after  their  interests  without  supervision. 

The  questions  which  have  to  be  answered  are  two — namely> 
(i)  Does  this  person  require  care,  supervision,  and  control,  either 
for  his  own  protection  or  for  the  protection  of  others  ?  and  (2)  Is 
such  care  necessitated  by  reason  of  mental  defect  from  birth  or 
from  an  early  age  ?  If  these  can  be  answered  in  the  affirmative, 
the  individual  is  a  mental  defective  within  the  meaning  of  the 
Act  of  1913. 

These  answers  can  only  be  given  after  a  careful  consideration 
of  the  data  regarding  his  previous  personal  history,  his  family 
history,  and  his  present  condition,  to  which  I  have  already  referred; 
but  I  think  if  this  be  done  there  will  rarely  be  any  great  difficulty 
in  arriving  at  a  decision.  It  is  obvious  that  the  previous  behaviour 
of  the  patient,  the  manner  in  which  he  has  adapted  his  conduct 
to  his  environment,  is  a  matter  of  the  utmost  importance,  and 
inquiry  on  this  point  should  be  most  thorough.  If  the  information 
for  any  reason  is  inadequate,  it  ma}'  often  be  supplemented,  and 
his  defect  demonstrated,  by  requiring  him  to  perform  some  special 
commission,  or  by  means  of  the  tests  which  have  been  described 
in  the  preceding  chapters. 

Consideration  of  the  data  revealed  by  the  three  lines  of  inquiry 
which  have  been  described  will  also  usually  avail  to  distinguish 
mental  defect  from  mental  perversion  or  insanit}-.  In  regard  to 
this,  it  may  be  stated  that  the  practitioner  must  be  upon  his  guard 


Diagnosis  during  Adolescence  and  Adult  Life     393 

against  attaching  too  much  importance  to  the  presence  of  delusions. 
It  is  to  be  remembered  that  whilst  delusions  are  common  both  in 
insanit}^  and  dementia,  they  may  also  occur  in  aments.  In  fact, 
insanity  with  delusions  is  a  not  infrequent  compHcation  of  mild 
mental  deficiency.  Similarly,  an  alternating  emotional  state 
suggestive  of  a  mild  form  of  manic-depressive  insanity  is  frequently 
observed  in  the  mentally  defective. 

A  person  who  recklessly  distributes  his  possessions  or  impoverishes 
himself  by  expending  large  sums  of  money  on  objects  for  which  he 
has  not  the  slightest  use,  under  the  delusion  that  he  is  acting  as  the 
almoner  of  the  Almighty  or  is  the  richest  man  on  earth,  is  probably 
insane  or  demented.  But  if  he  does  these  things  in  consequence 
of  an  inabihty  to  reahze  the  value  of  money,  and  his  purchases  are 
such  as  would  only  bring  dehght  to  a  child ;  if  he  shows  a  complete 
incapacity  for  business  management,  and  undue  credulity,  and  a 
lack  of  sense  of  responsibihty ;  if,  further,  he  is  content  to  be  left 
with  the  barest  necessities  of  life,  whilst  his  patrimony  is  plundered 
by  his  acquaintances  under  his  very  eyes,  and  if  this  condition  has 
been  present  from  an  early  age,  he  may  justly  be  regarded  as 
mentally  deficient. 

It  is  probably  with  regard  to  the  early  stages  of  dementia  that 
mistakes  are  most  likely  to  occur,  and  I  have  frequently  known 
persons  suffering  from  adolescent  or  juvenile  general  paralysis 
thought  to  be  aments,  and  recommended  for  admission  into  train- 
ing institutions  accordingly.  Even  if  no  history  is  available,  the 
presence  of  unequal  pupils,  tremor  of  tongue  or  mouth,  and  in- 
creased knee-jerks  in  the  general  paralytic  should  suffice  to  pre- 
\-ent  this  mistake.  Another  condition  which  may  be  confounded 
with  amentia  is  that  of  dementia  praecox,  and  it  must  be  admitted 
that  the  defect  of  judgment,  the  childish,  stereotyped  repetition  of 
words  and  phrases,  the  weakness  of  will,  and  the  diminished 
sensory  capacity  in  these  persons,  may  produce  a  picture  which, 
in  the  absence  of  any  history,  may  bear  some  superficial  resemblance 
to  primary  amentia.  But  it  is  only  superficial;  the  sufferer  from 
dementia  praecox  will  show  the  presence  of  rigidity,  increased 
reflexes,  catalepsy,  katatonia,  hallucinations,  complete  loss  of 
emotion,  or  other  signs  of  that  condition;  and  if  the  previous  history 
of  the  patient  is  forthcoming,  real  difficulty  can  hardly  arise.  It 
will,  of  course,  be  remembered  that  dementia  praecox  may  super- 
vene in  a  person  suffering  from  primary  amentia. 


394  Diagnosis  and  Prognosis 

Moral  Deficiency. — Perhaps  the  most  difficult  diagnostic  problem 
of  ail  is  that  of  distinguishing  between  moral  deficiency  and  ordinary 
criminality — ^between  madness  and  badness,  in  fact.  I  have 
already  remarked  that,  although  many  moral  defectives  also  show 
indications  of  intellectual  defect,  this  is  not  so  in  aU,  and  it  is  just 
these  cases  in  which  the  usual  signs  of  amentia  are  wanting,  that 
diagnosis  is  usually  called  for  and  is  particularly  difficult.  There 
is  not  the  slightest  doubt  that  every  year  many  persons  are  sen- 
tenced to  terms  of  imprisonment  for  offences  they  were  powerless 
to  avoid;  there  is  equally  no  doubt  that  the  plea  of  moral  defect 
is  often  put  forward,  and  accepted,  on  behalf  of  persons  who  should 
be  punished  for  their  acts.  The  question  has  already  been  dealt 
with  to  some  extent  in  speaking  of  criminal  responsibility  (p.  337), 
and  the  description  which  has  been  given  of  the  various  types  of 
moral  deficiency  should  enable  the  physician  to  examine  and  give 
an  opinion  upon  most  cases  of  this  kind.  No  hard-and-fast  rules 
can  be  laid  down;  each  case  must  be  judged  upon  its  merits,  and 
after  a  careful  consideration  of  the  life-history  of  the  individual, 
his  mental  status,  and  all  the  circumstances  attending  the  com- 
mission of  the  offence.  It  may  be  useful,  however,  briefly  to 
recapitulate  the  points  to  which  attention  must  especially  be 
paid. 

The  early  history  of  the  person  is  of  the  greatest  importance, 
for  the  reason  that  if  real  moral  defect  is  present,  it  can  hardly  fail 
to  have  shown  itself  in  disorder  of  conduct  from  a  comparatively 
early  age.  In  such  cases  the  examiner  will  therefore  usually 
find  that  the  child  was  addicted  to  lying  and  thieving,  and  acts 
of  gross  immorality.  He  may  have  been  dismissed  from  school 
because  he  was  found  to  be  generally  unmanageable;  and  it  will 
often  be  elicited  that,  instead  of  showing  any  contrition  for  his 
offences,  he  looked  upon  himself  as  ill-used.  Many  of  these  children 
are  very  plausible,  and  although  some  may  evince  a  certain  degree 
of  backwardness  in  particular  directions,  they  are  often  precocious 
in  others.  There  is,  to  my  mind,  no  doubt  that  offences  may  be 
committed  in  consequence  of  an  inability  to  inhibit  certain  immoral 
or  criminal  impulses;  but  I  should  regard  with  grave  suspicion  any 
plea  of  "  weak  will  "  which  was  put  forward  if  the  patient  had  not 
previously  shown  evidence  of  this  failing  in  the  shape  of  other 
impulsive  acts  during  childhood. 

The  nature  of  the  offence  itself  may  afford  valuable  indications. 


Diagnosis  of  Moral  Deficiency  395 

For  instance,  the  ordinary  criminal  will  steal,  or  otherwise  offend 
against  the  law,  because  of  some  seeming  advantage  which  out- 
weighs the  risk  of  possible  detection.  On  the  other  hand,  the 
morally  defective  person  may  have  no  adequate  motive  at  all;  he 
ma}^  have  no  use  whatever  for  the  articles  he  steals ;  and  he  will 
incur  punishment  upon  punishment  without  being  able  to  desist 
from  his  evil  practices. 

The  moral  imbeciles,  as  now  legally  recognized  by  the  Mental 
Deficiency  Act,  come  within  a  much  narrower  scope,  in  that  they 
are  defined  as  "  persons  who  from  an  early  age  displa}^  some  per- 
manent mental  defect,  coupled  with  strong  vicious  or  criminal  pro- 
pensities on  which  punishment  has  had  little  or  no  deterrent  effect." 
The  presence  of  mental  defect  must  be  ascertained  by  the  methods 
already  described,  whilst  the  history  will  show  whether  the  latter 
part  of  the  definition  is  fulfilled. 

PROGNOSIS. 

Until  sixty  years  ago  cases  of  pronounced  mental  deficiency 
were  considered  to  be  absolutely  and  hopelessly  beyond  any  possi- 
bility of  amehoration.  But  in  1846  Dr.  Edouard  Seguin*  demon- 
strated to  the  world  the  capacity  possessed  by  many  of  these  per- 
sons for  considerable  improvement  under  patient  and  systematic 
training,  and  since  then  the  pendulum  has  gradually  swung  to  the 
other  extreme.  At  the  present  day  the  training  of  the  mentally 
deficient  occupies  a  more  or  less  important  place  in  the  social 
system  of  most  civilized  countries,  and  it  is  even  questionable 
if  there  be  not  a  tendency  to  overestimate  the  educational  possi- 
bilities, and  to  think  that  the  machine  only  needs  to  be  sufficiently 
elaborate  for  the  entering  idiot  to  emerge  a  person  of  normal 
intelligence. 

Both  these  views  are  wrong,  and  are  to  be  deprecated.  On  the 
one  hand,  there  are  comparatively  few  cases  so  bad  that  they  cannot 
be  improved  to  some  extent,  if  only  in  habits  of  cleanliness  and  the 
curtailing  of  destructive  and  dangerous  propensities.  On  the  other 
hand,  no  case  of  real  amentia  (with  the  possible  exception  of 
cretinism)  ever  becomes  cured.  However  mild  it  may  be,  some 
defect  will  always  remain,  and  this  will  render  competition  on  an 
equal  footing  with  the  normal  population  impossible. 

*  fidouard  S6g^in,  "  Idiocy,  and  its  Treatment  by  the  Physiological 
Method,"  New  York,  1866. 


39^  Diagnosis  and  Prognosis 

And  here  it  is  necessary  to  enter  a  protest  against  the  practice 
adopted  by  some  medical  men  of  telling  the  parents  that  the  child 
will  "  grow  out  of  it,"  or  that  he  will  be  "  all  right  when  he  is 
seven,"  or  "  fourteen,"  or  "  twenty-one."  In  some  cases  this  is 
done  from  ignorance  of  what  amentia  really  is,  in  others  from  a. 
benevolent  but  mistaken  idea  of  sparing  the  parents'  feelings. 
Where  the  physical  condition  of  the  patient  is  such  that  death, 
cannot  be  long  delayed,  the  disquieting  knowledge  that  idiocy  is 
present  may  perhaps  be  withheld;  but  in  other  cases  the  interests 
of  the  patient  demand  that  the  parents  should  be  told  the  truth, 
for  much  of  the  early  training  so  necessary  for  improvement  MdlL 
be  in  their  hands.  I  have  known  children  dragged  about  from 
doctor  to  doctor  and  from  quack  to  quack  in  the  vain  hope  of 
seeing  that  change  which  had  been  confidently  foretold,  but  which. 
never  came.  I  have  known  many  pounds  spent  on  nostrums, 
electrical  and  galvanic  appliances,  whilst  the  child  was  rapidly 
deteriorating  for  want  of  systematic  training;  but  I  have  rarely 
met  parents  who  were  other  than  grateful,  though  sad,  when  the 
real  truth  was  kindly  told  them.  Few  people  like  living  in  a  fool's 
paradise,  and  in  this  case  it  is  not  a  paradise,  for  there  is  often  the- 
lurking  suspicion  that  something  is  really  wrong,  and  that  the- 
practitioner  does  not  understand  the  case. 

To  what  extent,  then,  may  the  patient  be  improved  by  treat- 
ment ?  ■  No  absolute  forecast  can  be  given,  but  attention  to 
certain  considerations  regarding  the  form,  variety,  and  degree  of 
amentia  will  enable  a  tolerably  accurate  prognosis  to  be  given  in 
most  cases. 

Prognosis  ol  the  Forms  of  Amentia. — As  a  rule  cases  of  primary 
amentia  are  much  more  capable  of  improvement  than  are  those  of 
the  secondary  form.  In  other  words,  contrary  to  what  would  be 
expected  from  their  appearance,  the  stunted,  misshapen,  and  often 
repulsive-looking  victims  of  morbid  heredity  are  more  responsive 
to  training  than  are  the  well-grown,  and  often  well-favoured, 
sufferers  from  accidental  injury  or  disease  of  the  brain.  This 
dictum  was  enunciated  by  Langdon  Down  many  years  ago,  in  the 
words  that  the  prognosis  is  favourable  "  inversely  as  the  child  is 
comely,  fair  to  look  upon,  and  winsome,"  and  experience  has  fully 
confirmed  its  general  truth.  The  explanation  of  this  apparent 
anomaly  is  that  in  the  latter  group  we  have  to  do  with  destructive 
lesions,  whose  course  is  often  progressive,  and  which,  by  inducing 


Prognosis  397 

a  general  disturbance  of  the  whole  function  of  the  brain,  make 
education  impossible.  In  the  former,  on  the  other  hand,  although 
neuronic  development  is  irregular  and  incomplete,  there  is  often  no 
actual  disease. 

Prognosis  in  Different  Varieties.  —  The  foregoing  statement, 
however,  is  not  rigidly  exact,  for  the  result  is  to  some  extent  de- 
pendent upon  the  variety  of  amentia  present.  The  prognosis  of 
the  respective  varieties  may  be  summarized  as  follows : 

In  simple  primary  amentia  the  result  is  hopeful  or  the  reverse 
in  proportion  to  the  degree  of  deficiency  and  the  presence  of  epilepsy 
or  paralysis. 

In  microcephalics,  with  the  exception  of  extreme  instances,  a 
considerable  amount  of  improvement  may  be  predicted,  and  the 
patient  may  eventually  become  capable  of  many  simple  routine 
tasks  not  requiring  thought.  But  he  will  always  be  markedly 
deficient  in  mental  capacity. 

In  Mongolians  the  prognosis  is,  generally  speaking,  directly 
proportionate  to  the  intensity  of  the  bodily  signs.  The  milder 
cases,  as  a  result  of  appropriate  training,  may  almost  come  to  pass 
muster  with  their  brothers  and  sisters ;  but  they  will  always  require 
someone  to  manage  their  affairs.  Many  of  the  more  pronounced 
cases,  even,  can  be  taught  to  do  some  useful  work  in  the  garden 
or  on  the  farm.  But  the  actual  performance  of  Mongolians  never 
comes  up  to  what  might  be  expected  from  their  vivacious  and  often 
comparatively  intelligent  appearance. 

In  cases  of  secondary  amentia  due  to  toxic  or  vascular  disease  of 
the  brain,  the  prognosis,  as  already  remarked,  is  on  the  whole  de- 
cidedly less  favourable  than  in  primary  aments;  but  it  differs  very 
greatly  according  to  the  nature  of  the  lesion.  In  cases  where, 
after  the  infliction  of  the  damage,  the  pathological  lesion  ceases  to 
progress,  and  serious  secondary  anatomical  changes  are  not  induced, 
the  prognosis  is  tolerably  good,  always  provided  that  appropriate 
training  is  begun  sufficiently  early.  Many  cases  of  birth  injury 
and  purely  vascular  lesions  occurring  in  very  early  life  are  of  this 
nature,  and  the  improvement  is  probably  brought  about  by  neuronic 
compensation.  Many  of  these  persons  who  suffer  from  severe 
paralysis  even  may  be  educated  to  read,  write,  sum,  and  do  me- 
chanical work  with  surprising  dexterity;  but  there  is  usually  a 
little  childishness,  a  want  of  judgment  regarding  the  affairs  of  life, 
and    an    inability    to    make    headway    against    competition.     Dr. 


398  Diagnosis  and  Prognosis 

Shuttleworth*  mentions  such  a  case  presenting  right  hemiplegia 
with  athetosis  attributed  to  injury  at  birth,  who  was  admitted  into 
the  Royal  Albert  Asylum  at  the  age  of  twelve  years.  "  In  spite 
of  his  physical  drawbacks,  he  rapidly  developed  graphic  abihties, 
and  after  a  course  of  scholastic  instruction  in  writing,  drawing, 
reading,  etc.,  with  suitable  physical  and  manual  exercises,  he  was 
trained  to  woodwork  in  the  joiner's  shop,  which  he  gradually 
attained  such  control  over  his  irregular  movements  that  he  became 
an  expert  workman,  making  tables,  chests  of  drawers,  and  decor- 
ative sideboards.  He  showed  a  nice  taste  for  wood-carving,  and 
ultimately  became  so  skilful  in  it  that  he  is  now  employed  as  in- 
structor in  this  art.  He  is  also  a  clever  scene-painter.  He  is  now 
practically  ambidextrous,  his  right  hand  having  been  trained  to 
be  serviceable." 

It  is,  of  course,  to  be  remembered  that  in  many  of  these  cases  of 
birth  paralysis  the  lesion  concerns  the  motor  centres  of  the  brain 
only,  the  child  subsequently  appearing,  but  not  in  reality  being, 
mentally  deficient  because  his  crippled  condition  has  prevented 
his  attendance  at  school. 

On  the  other  hand,  in  cases  where  the  lesion  is  active  or  induces 
progressive  pathological  changes,  the  prognosis  is  decidedly  un- 
favourable, and  in  a  considerable  number  dementia  sooner  or  later 
supervenes.  The  majority  of  these  are  characterized  by  epilepti- 
form or  epileptic  convulsions. 

Amentia  due  to  epilepsy  is  decidedly  unfavourable,  being,  in  fact, 
one  of  the  most  hopeless  varieties.  For  epilepsy  which  has  pro- 
duced amentia  will  probably  end  by  producing  dementia.  In 
other  cases  of  mental  deficiency,  in  which  epilepsy  is  a  complication 
and  not  the  cause,  it  is  still  a  highly  unfavourable  symptom,  and 
imposes  a  considerable  barrier  to  successful  education. 

In  sclerotic  amentia  the  most  hopeful  cases  are  those  in  which 
enlargement  of  the  skull  takes  place.  The  majority  of  cases  of 
pronounced  sclerosis  with  crania  of  normal  or  diminished  size  die 
before,  or  soon  after,  attaining  the  age  of  puberty. 

In  hydrocephalus  everything  depends  upon  the  course  of  the 
disease,  which  can  never  be  foreseen.  Rapidly  progressing  expan- 
sion of  the  skull  is  almost  invariabl}'  fatal;  but  in  cases  where 
spontaneous  arrest  takes  place,  the  resulting  mental  impairment 

*  G.  E.  Shuttleworth,  "  Mental  Deficiency  in  Children,"  British  Journal 
of  Chiidyen's  Diseases,  March,  1904. 


Prognosis  399 

may  be  but  slight,  and  may  be  largely  remedied  by  suitable 
training. 

In  syphilitic  amentia,  in  view  of  the  tendenc}'  to  the  develop- 
ment of  general  paralysis,  the  outlook  is  decidedly  bad,  whilst  in 
infantile  cerebral  degeneration  it  is  hopeless. 

In  cretinism  the  prognosis  is  on  the  whole  dependent  upon  the 
age  at  which  treatment  is  begun  and  the  persistence  with  which 
it  is  carried  out.  As  already  mentioned,  however,  it  is  possible 
that  other  factors  may  influence  the  result — e.g.,  the  presence  or 
absence  of  morbid  heredity. 

Amentia  due  to  isolation  or  sense  deprivation  is  curable  provided 
special  education  is  begun  sufficiently  early,  and  even  in  cases 
which  have  been  neglected  for  years  it  is  remarkable  what  results 
may  foUow  patient  and  systematic  training. 

Prognosis  regarding  the  Degree. — It  is  obvious  that  the  less 
the  innate  potentiality  for  development,  the  greater  will  be  the 
amount  of  permanent  defect.  At  the  same  time  the  results  of 
training  are  often  very  considerable,  and  by  this  means  a  child 
who  would  in  its  absence  be  a  helpless  idiot  may  make  considerable 
developmental  progress.  On  the  other  hand,  the  child  possessing 
a  potentiality  which  might  have  been  turned  to  good  account  may, 
by  neglect  in  early  life,  never  develop  beyond  the  status  of  aa 
imbecile  or  idiot. 


CHAPTER  XIX 
TREATMENT  AND  TRAINING 

L— MEDICAL  AND  SURGICAL  TREATMENT. 

In  view  of  the  fact  that  primary  amentia — to  which  form  the 
great  majority  of  cases  of  mental  deficiency  belong — is  due  to  a 
diminished  innate  potentiality  for  development — in  other  words, 
to  a  formative  defect  of  the  tissue  which  constitutes  the  physical 
basis  of  mind — it  is  hardly  to  be  expected  that  medicaments  would 
have  any  remedial  effect,  and,  as  a  matter  of  fact,  there  is  no  drug 
which  has  the  slightest  direct  or  specific  influence  upon  this  con- 
dition. Cases  of  secondary  amentia,  however,  stand  on  a  different 
plane,  in  that  in  them  the  mental  defect  is  not  due  to  an  innate 
blight,  but  to  the  fact  that  development  has  been  handicapped  or 
arrested  by  some  external  factor,  and  where  this  can  be  overcome 
by  the  administration  of  drugs,  a  considerable  improvement,  or 
even  cure,  may  be  brought  about. 

We  have  a  remarkable  and  well-known  instance  of  this  in  the 
thyroid  treatment  of  cretinism.  The  future  may  even  show  that 
there  are  other  varieties  of  secondary  amentia  which  are  due  to 
definite  glandular  defects  or  particular  disorders  of  nutrition,  and 
for  these  also  the  corresponding  specific  may  be  found.  As  I  have 
already  mentioned,  it  is  possible  that  Mongolism,  which  is  now 
classed  as  a  variety  of  primary  amentia,  may  eventually  prove 
to  have  such  a  causation,  and  to  belong  to  the  secondary  group. 
At  the  same  time  the  cases  which  may  possibly  be  treated  in  this 
way  are  few  in  number,  and  in  the  great  majority  of  instances  of 
secondary  as  well  as  of  primary  amentia  it  must  be  said  that  drugs 
have  no  direct  influence.  Extracts  from  the  pituitary,  thymus, 
and  other  glands  have  now  been  tried  for  a  considerable  number 

400 


Medical  and  Surgical  Treatment  401 

of  years,  with  practically  no  result,*  and  even  the  amentia  which 
is  directly  due  to  syphilis  has  hitherto  shown  not  the  slightest 
improvement  under  antisyphilitic  treatment. 

The  same  must  be  said  of  surgical  treatment.  When  the  theory 
was  propounded  that  microcephalus  was  due  to  premature  synos- 
tosis, it  was  natural  that  the  surgeon  should  suggest  relief  by  crani- 
ectomy. During  the  year  1890,  and  for  a  time  after,  a  considerable 
number  of  operations  were  performed  by  eminent  men,  chief  of 
whom  may  be  mentioned  Lannelongue  (Paris),  Victor  Horsley 
(London),  and  Keen  (Philadelphia).  The  cases  operated  upon  were 
not  only  microcephalics,  but  included  other  varieties  of  amentia. 
The  mortality  was  exceedingly  high  (about  25  per  cent.),  and  those 
who  survived  showed  no  mental  improvement.  It  is  not  surprising 
that  the  operation  should  have  gradually  been  abandoned  by 
reputable  surgeons,  and  to-day  it  is  practically  unheard  of.  It 
was,  indeed,  founded  upon  a  mistaken  notion  as  to  the  pathology 
of  this  condition,  and  it  may  be  said  that  to-day  operations  of  this 
kind  upon  cases  of  primary  amentia  are  absolutely  unjustifiable. 
The  same  must  be  said  of  the  operation  of  paracentesis  in  hydro- 
cephalus. 

The  case  is  somewhat  different  with  regard  to  certain  varieties 
of  secondary  amentia.  Where  there  is  no  morbid  heredity,  and 
where  there  is  clear  evidence,  or  even  a  reasonable  presumption, 
that  the  deficiency  is  due  to  fracture,  splintering  of  the  inner  table, 
the  pressure  of  a  blood-clot,  or  other  conditions  causing  increased 
cranial  pressure,  then  not  only  is  operation  justifiable,  but  it  is  the 
duty  of  the  physician  to  advise  it  at  the  earliest  possible  moment, 
and  before  changes  have  been  induced  which  may  be  irreparable. 
I  must  confess,  however,  that  I  know  of  no  statistics  sufficiently 
■extensive  to  show  the  results  of  operation  in  such  cases. 

Nevertheless,  it  is  not  to  be  assumed  that  medicine  or  surgery 
have  no  place  in  the  treatment  of  amentia.  This  is  far  from  being 
the  case,  for  mens  sana  in  corpore  sano  is  a  true  saying,  and  medicine 
and  surgery  can  do  much  to  promote  the  bodily  well-being  of  these 

*  Dr.  A.  S.  Woodwark  (St.  Bartholomew's  Hospital  Reports,  191 2),  has 
recently  been  using  tablets  consisting  of  i  grain  each  of  thyroid,  thymus, 
suprarenal,  and  pituitary  glands.  He  found  that  three  Mongolian  im- 
beciles, aged  six,  four,  and  two  years  respectively,  to  whom  these  were  ad- 
ministered were  improved  mentally,  becoming  cleaner,  quieter,  and  more 
intelligent.  But  although  these  results  are  extremely  interesting,  the  lapse 
of  time  and  many  more  observations  will  be  needed  before  a  delinite  opinion 
^an  be  formed  as  to  their  value. 

26 


402  Treatment  and  Training 

persons.  I  am  no  advocate  for  the  systematic  drenching  of  the 
ament  with  drugs,  or  for  the  performance  upon  him  of  operations 
which  can  contribute  nothing  to  the  improvement  of  his  body  or 
mind;  but  it  cannot  be  doubted  that  conditions  are  often  present 
which  stand  in  the  way  of  efficient  training  and  which  are  amenable 
to  treatment;  and  it  is  certain  that  education  will  be  attended  with 
most  success  when  every  means  have  been  employed  to  place  the 
body  in  the  best  possible  condition. 

Before  systematic  education  is  begun,  therefore,  it  is  of  great 
importance  to  ascertain  the  existence  of  disease,  disorder,  or  de- 
formity, and  to  correct  the  same  by  appropriate  remedies,  if  such 
be  possible.  It  is  unnecessary  to  describe  all  the  diseases  and 
ailments  which  may  affect  the  mentally  deficient  child ;  their  name 
is  legion,  and  the  chief  of  them  have  already  been  referred  to  in 
previous  chapters.  It  may  be  stated,  however,  that  conditions 
which  particularly  call  for  treatment  are  adenoids,  enlarged  tonsils, 
nasal  polypi,  cleft  palate,  carious  teeth,  errors  of  refraction,  disease 
of  the  ear,  phimosis,  hernia,  webbing  of  the  fingers,  etc.  Trouble- 
some contractures  may  often  be  relieved  by  tenotomy,  and  where 
club-foot  is  present,  walking  may  be  greatly  improved  by  suitable 
surgical  boots.  Asexualization  has  been  vaunted  as  a  remedy  for 
some  of  the  iUs  of  the  ament,  but  although  benefit  seems  to  have 
resulted  in  some  cases,  the  effects  are  too  contradictory  to  make 
it  an  operation  which  should  be  advocated.  Medical  treatment 
is  caUed  for  in  ansmia,  malnutrition,  and  many  disorders  of  the 
circulatory,  respiratory,  alimentary,  and  cutaneous  systems. 
Troublesome  constipation  is  best  met  by  attention  to  the  diet  and 
the  administration  of  cascara  sagrada.  Diarrhoea  is  often  caused 
by  imperfect  mastication  or  unsuitable  food,  and  may  need  anti- 
septic or  astringent  treatment.  Extract  of  malt,  with  or  without 
cod-liver  oil,  is  valuable  in  severe  malnutrition.  Epilepsy  is  best 
treated  by  a  careful  control  of  the  diet  and  daily  life ;  but  if  this 
fails,  the  frequency  and  severity  of  the  attacks  are  often  checked 
by  borax  and  the  bromides.  A  single  dose  of  the  latter  at  bed- 
time is  often  useful  in  allaying  the  undue  instabihty  so  common  in 
many  of  the  milder  defectives.  Enuresis,  a  frequent  comphcation, 
is  best  treated  by  accustoming  the  child  to  evacuation  at  regular 
periods.  It  may  be  helped  by  withholding  all  fluid  for  at  least  two 
hours  before  retiring,  and  in  many  cases  a  few  nightly  doses  of  one 
of  the  bromides  will  serve  to  check  the  habit.     I  have  often  found 


Education  403 

good  results  follow  a  mixture  of  bromide  of  potassium  and  Parrish's 
Chemical  Food;  whilst  belladonna  is  another  remedy  which  is  often 
successful.  In  some  cases  of  enuresis  thyroid  extract  has  been  used 
with  marked  success.  The  initial  dose  is  J  to  |  grain  of  the  dried 
extract  daily,  which  may,  if  necessary,  be  gradually  increased 
until  symptoms  of  thyroidism  appear.* 

In  addition  to  these  indications  for  special  treatment,  the  food, 
clothing,  exercise,  cleanliness,  and  general  hygiene  of  these  persons 
demand  the  closest  attention.  The  dietary  must  be  on  a  liberal 
scale,  but  plain,  and  excess  of  meat  must  carefully  be  avoided. 
Where  mastication  is  imperfect,  recourse  to  spoon  food  is  often 
necessary,  and  this  is  always  the  case  with  the  low-grade  idiots. 
The  danger  of  asphyxia  from  the  impaction  of  food  in  the  glottis 
is  no  fancy,  and  many  cases  of  aspiration  pneumonia  have  been 
recorded.  Attention  to  the  clothing  is  particularly  called  for  in 
the  Mongolian  variet\',  as  well  as  in  other  patients  prone  to  catarrhal 
and  circulatory  disturbances.  In  the  cold  weather,  the  wearing  of 
gloves  may  prevent  troublesome  chilblains.  Daily  exercising  and 
bathing  must  always  be  enforced,  and  the  greatest  care  must  be 
taken  that  rooms  are  sunny,  not  too  warm,  and  thoroughly  well 
ventilated.  The  marked  predisposition  which  many  of  these 
persons  evince  to  the  development  of  tuberculosis  must  be  kept 
well  in  mind. 

It  is  unnecessary  to  enter  any  further  into  the  details  of  medical, 
surgical,  and  hj^gienic  treatment,  since  the  principles  are  the  same 
in  these  as  in  ordinary  children.  The  only  point  I  wish  to  insist 
upon  is  that  mental  deficiency  is  often — indeed,  usually — accom- 
panied by  bodily  deficiency,  disorder,  and  disease,  and  that  the 
treatment  of  these  latter  is  an  essential  prelude  to,  or  accompaniment 
of,  the  training  of  the  mind. 

II.— EDUCATION. 

General  Principles. 

Having  done  our  best,  by  careful  attention  to  the  laws  of  hygiene 
— aided,  where  necessary,  by  medicine  and  surgery — to  remove  any 
likely  impediments  to  training,  and  to  bring  the  mentally  deficient 

*  On  the  subject  of  "  Enuresis  and  Thyroid  Extract,"  see  an  interesting 
account  of  twenty-eight  cases  by  Dr.  A.  C.  D.  Firth  in  Lancet,  December  9, 
1911 ;  also  a  paper  by  Dr.  Leonard  WiUiams  in  Lancet,  May  i,  1909. 


404  Treatment  and  Training 

child  into  the  best  possible  physical  condition,  the  question  of 
education  must  be  considered.  In  the  following  pages  I  shall  deal 
with  the  general  principles  upon  which  such  should  be  based, 
particularly  those  which  concern  the  physician.  The  actual 
pedagogic  methods  to  be  employed  are  beyond  the  scope  of  this 
work,  and,  for  the  most  part,  can  only  be  acquired  by  practical 
experience. 

Education  has  a  threefold  object.  First,  it  should  develop  and 
cultivate  all  the  latent  potentialities  of  body  and  mind  to  their 
fullest  extent;  secondly,  it  should  repress  or  eliminate  vices  and 
faulty  modes  of  action;  thirdly,  it  should  supply,  if  possible,  such 
particular  instruction  as  will  fit  the  individual  for  some  useful 
form  of  work.  In  other  words,  it  should  aim  at  imparting  know- 
ledge as  well  as  inculcating  wisdom.  The  two  former  of  these 
objects  are  educational  in  the  literal  sense  of  the  word;  the  latter 
may  be  looked  upon  as  technical  instruction. 

The  development  of  mind  takes  place  in  consequence  of  two  influ- 
ences: spontaneity,  or  an  inherent  tendency  of  the  brain  cells  to 
develop;  and  stimulation  of  these  cells  by  external  impressions. 
The  brain  of  the  healthy  child  has  an  inherent  potentiality  which 
makes  it  to  a  certain  extent  independent  of  its  environment;  or 
perhaps  I  should  rather  say  that  it  is  capable  of  utilizing  and  re- 
sponding to  any  surroundings,  within  ordinary  limits,  in  which  it 
may  be  placed.  A  little  friend  of  mine,  aged  four  years,  reads 
"  Alice  in  Wonderland  "  with  remarkable  facility.  She  has  never 
had  a  single  formal  lesson,  and  her  knowledge  was  picked  up  solely 
by  observing  letters  and  asking  questions.  The  defective  mind  is 
lacking  in  this  power.  One  of  its  chief  characteristics,  if  not  the 
chief,  is  a  want  of  what  may  be  termed  mental  aggressiveness  ;  con- 
sequently its  development  has  to  be  aided  and  encouraged  by  special 
means.  At  the  same  time,  the  deficient  power  of  control  often 
gives  fuU  play  to  the  lower  organic  feelings,  resulting  in  vices, 
antisocial  acts,  and  crimes.     These  tendencies  have  to  be  eliminated. 

Until  sixty  years  ago  the  training  of  the  mentally  deficient, 
where  such  was  attempted,  was  conducted  upon  no  logical  method, 
and  it  is  to  Dr.  Edouard  Seguin  that  we  owe  the  first  clear  enuncia- 
tion of  the  principles  upon  which  it  should  be  based.  In  his  words, 
education  "  consists  in  the  adaptation  of  the  principles  of  physi- 
ology, through  physiological  means  and  instruments,  to  the  de- 
velopment of  the  dynamic,  perceptive,  reflective,  and  spontaneous 


Education  405 

functions  of  youth."  By  the  painstaking  and  laborious  applica- 
tion of  these  principles,  Seguin  himself  demonstrated  the  remarkable 
results  which  may  take  place  even  in  apparently  hopeless  idiots; 
and  upon  his  principles,  extended  and  elaborated  by  the  work  of 
Froebel  and  Pestalozzi,  most  of  our  present  methods  are  based. 

The  method  of  applying  these  principles,  in  brief,  is  to  take  each 
"  function  "  or  "  faculty,"  each  physiological  system  of  neurones, 
and,  by  means  of  appropriate  and  carefully  arranged  progressive 
exercises,  to  develop  them  to  the  fullest  extent  of  their  capacity. 
I  do  not,  of  course,  mean  to  suggest  that  we  can  isolate  and  develop 
separately  each  "  function."  All  portions  of  the  mental  apparatus 
are  interdependent,  and  education  is  a  general  process  which  simul- 
taneously concerns  the  development  of  the  bodily  as  well  as  the 
sensory,  motor,  intellectual,  emotional,  and  moral  functions.  But 
it  is  convenient  for  purposes  of  description  to  make  this  division, 
and  it  tends  to  emphasize  the  fact,  that  as  the  child's  development 
naturally  takes  place  in  a  regular  progressive  order,  so  must  the 
training  be  progressively  adapted  to  its  growing  needs. 

In  many  cases  it  is  first  of  all  necessary  to  arouse  spontaneity. 
The  child  is  inert,  and  must  even  be  stimulated  to  play;  until  this 
is  accomplished,  and  some  interest  is  aroused,  any  further  training 
is,  of  course,  impossible.  Having  succeeded  in  arousing  some 
degree  of  initiative  b3^  means  of  romping  play,  this  is  gradually 
replaced  by  more  definite  games,  and  then  by  orderly  drill  and 
calisthenics.  In  this  way  spontaneity  becomes  controlled  in 
accordance  with  a  definite  purpose,  and  the  child  learns  to  acquire 
the  habits  of  obedience  and  attention.  This  naturally  leads  up  to 
still  more  regular  and  systematized  exercises,  in  the  shape  of  such 
kindergarten  occupations  as  building  with  cubes,  stick-laying, 
bead-threading,  pricking  outlines,  knotting  and  looping,  paper 
cutting  and  folding;  and  these,  in  turn,  are  superseded  by  clay- 
modelling,  macrame  work,  knitting  and  darning,  and  finally  by 
definite  technical  instruction  in  wood-carving,  carpentry,  basket- 
weaving,  mat-making,  needlework,  laundry  work,  and  dressmaking, 
etc.  Coincidently,  speech  is  cultivated,  instruction  is  given  in  the 
three  R's,  and  every  care  is  taken  to  repress  injurious  propensities 
and  to  develop  moral  character. 

The  general  principles  of  education  do  not  differ  from  those 
in  the  case  of  the  mentally  normal,  the  difference  being  merely  one 
of  method  and  apphcation.     The  whole  object  of  the  teacher  is 


4o6  Treatment  and  Training 

to  reduce  the  environment  of  the  child  to  a  form  which  the  deficiency 
of  his  mind  is  capable  of  cissimilating,  at  the  same  time  taking  care 
that  his  mental  pabulum  is  administered  in  an  attractive  shape. 
It  may  safely  be  said  that  no  success  will  be  attained  unless  the 
child's  interest  is  aroused,  and  this  must  be  the  teacher's  first  care. 
It  is  by  means  of  this  interest  and  its  progressive  expansion,  by 
gradually  leading  him  step  by  step  from  one  acquirement  to  another, 
that  the  capacity  of  the  child  is  unfolded  and  that  his  education 
is  accomplished.  In  many  cases  even  destructive  tendencies, 
where  the  child  will  do  nothing  but  tear  into  pieces  everything  given 
to  him,  may  be  made  use  of  as  the  first  stepping-stone  to  manual 
work.  Above  all,  it  is  necessary  to  remember  that  these  children's 
conception  of  the  abstract  is  extremely  limited,  that  ever^'thing 
must  be  presented  in  the  concrete,  and  that  they  will  learn  far  more 
with  their  hands  than  with  their  heads. 

It  is  necessary  to  pay  particular  attention  to  the  cultivation  of 
the  sensory  and  motor  functions.  In  the  ordinary  child  these  are 
perfected  as  the  result  of  his  own  initiative,  but  in  the  ament  special 
stimulation  is  required — not  only  because  of  the  presence,  in  a 
considerable  proportion  of  these  children,  of  defects  and  irregu- 
larities of  nerve  action  (abnormal  nerve  signs),  which  must  be 
corrected  before  useful  manual  work  can  be  accomplished,  but 
because  such  training  affords  a  most  valuable  means  of  developing 
and  co-ordinating  intellectual  activity. 

Thus,  by  means  of  suitable  impressions  through  e3'e,  ear,  skin, 
muscle,  nose,  and  mouth,  the  range  and  delicacy  of  the  sensorium 
is  increased,  the  brain  rendered  more  receptive,  the  power  of  dis- 
crimination, as  well  as  motor  response,  encouraged,  and  a  basis 
supphed  for  future  thoughts  and  ideas.  We  hve,  of  course,  in  a 
perfect  sea  of  sights,  sounds,  and  vibrations  of  every  kind,  and, 
as  already  remarked,  the  healthy  brain  is  so  constituted  that  it 
can  utilize  these  without  any  special  tutorial  help.  I  do  not  say 
that  this  is  likely  to  lead  to  an  optimum  result;  in  fact,  I  believe 
that  the  mental  capacity  of  even  the  health}^  child  would  be  greatly 
improved  by  a  course  of  sensory  training  on  ph3'siological  lines. 
It  is  doubtful  whether  the  mental  development  of  anyone,  even  the 
best,  comes  up  to  the  inherent  possibilities.  In  the  case  of  the 
defective  mind,  however,  such  a  course  of  training  is  usually 
absolutely  necessary,  and  constitutes  a  most  important  part  of 
education. 


Education  407 

Similarly  with  regard  to  the  motor  system.  All  mental  action 
is  expressed  by  movement,  or  inhibition  of  movement,  of  some 
kind  or  other.  It  may  be  the  mere  opposition  of  the  thumb  and 
forefinger,  the  play  of  facial  expression,  the  complicated  mechanism 
of  speech,  or  the  deliberate  conformation  of  the  whole  being  to 
some  emotion  or  ideal,  as  seen  in  conduct  and  behaviour.  Since 
it  is  by  the  character  of  his  movements  and  actions  and  general 
behaviour  that  the  entire  relationship  of  the  mentally  deficient 
child  to  the  rest  of  society  will  be  determined,  it  is  plain  that  the 
development  of  the  motor  system  is  of  the  greatest  importance. 
We  may,  indeed,  say  that  all  means  for  the  cultivation  of  mental 
faculty  are  of  importance  according  as  they  develop,  co-ordinate, 
and  control  mental  manifestations — i.e.,  movements. 

Such,  then,  are  the  general  principles  upon  which  the  educa- 
tion of  the  mentally  deficient  child  must  be  based,  and  of  which 
some  further  details  will  be  given  presently.  It  is  obvious,  how- 
ever, that  although  we  must  be  guided  by  these  principles,  the 
measure  of  success  achievable  will  vary  enormously,  and  will  be 
dependent  upon  the  degree  of  initial  defect — or  perhaps  I  should 
rather  say  upon  the  inherent  capacity  for  development  present  in 
any  particular  case.  This  cannot  be  foretold;  but  undoubtedly 
there  is  a  limit,  and  a  point  is  at  last  reached  beyond  which  no 
further  advance  takes  place. 

In  the  idiots  we  shall  get  no  farther  than  the  implanting  of 
habits  of  cleanliness,  the  development  of  some  capacity  for  self- 
feeding  and  self-help,  the  curtailing  of  destructive  and  vicious  pro- 
pensities, and  the  expression,  by  signs  or  words,  of  simple  wants- 
And  we  may  not  get  even  so  far  as  this.  In  the  imbeciles  a  higher 
stage  will  be  attainable,  and  not  onty  may  they  be  made  to  be 
much  more  self-helpful  and  less  dependent,  but  they  may  even  be 
taught  to  perform  a  certain  amount  of  useful  routine  work.  Lastly, 
in  the  case  of  the  feeble-minded  the  result  achieved  may  be  very 
considerable.  A  goodly  number  will  become  orderly,  industrious, 
and  well-behaved  individuals,  perhaps  able  to  read  and  write  a 
little,  to  do  simple  sums,  and  capable  of  performing  useful  work, , 
which  will  at  the  same  time  keep  them  happily  engaged  and,  where 
necessary,  contribute  to  their  support.  But  cure  will  never  take 
place. 

We  now  may  refer  to  some  points  regarding  the  application  of 
these  principles  to  home  and  school  training. 


4o8  Treatment  and  Training 

Home  Training. 

The  training  of  the  mentally  deficient  child  should  begin  at 
birth,  or  as  soon  as  the  condition  is  diagnosed.  The  ament,  even 
more  than  the  normal  child,  rapidly  develops  bad  habits,  and 
care  in  the  early  years  of  life  may  not  only  do  much  to  prevent  these, 
but  will  be  of  the  greatest  assistance  in  paving  the  way  for  the 
more  systematic  training  of  after-years.  This  early  training  must 
of  necessity  be  carried  out  at  home,  and,  where  circumstances 
permit,  it  is  advisable  that  it  should  be  at  the  hands  of  a  trained 
governess;  but  where  this  is  not  possible  it  must  be  undertaken  by 
the  parents.  In  any  case,  the  growth  and  well-being  of  the  child's 
mind,  as  well  as  body,  should  be  under  the  general  supervision  of 
the  medical  attendant. 

I  have  already  emphasized  the  necessity  for  telling  the  parents 
the  truth  regarding  the  condition  of  their  child ;  I  would  here  remark 
that  it  is  also  the  physician's  duty  to  state  plainly  that  neglect 
at  this  time  may  mean  the  development  of  habits  which  it  may 
take  years  to  eradicate;  whilst  care,  kindness,  and,  above  all, 
patience,  will  certainly  result  in  improvement.  Suitable  food, 
clothing,  warmth,  exercise,  fresh  air,  regular  bathing — in  fact, 
attention  to  all  concerning  the  general  bodily  health — are  of  the 
first  importance,  whilst  the  habit  of  cleanliness  cannot  be  enforced 
too  early.  Its  acquirement  in  all  but  the  most  degraded  idiots 
is  usually  only  a  matter  of  patience.  With  regard  to  training, 
there  is  no  need  for  anything  elaborate;  but  the  practice  of  rele- 
gating these  children  to  out-of-the-way  corners,  and  of  depriving 
them  of  those  adjuncts  to  development  which  they  need  far  more 
than  do  ordinary  children,  is  one  which  cannot  be  too  strongly 
condemned.  What  is  required  at  this  time  is  a  little  more,  and 
not  a  little  less,  care  and  patience.  The  child  must  be  talked  to 
and  encouraged  to  play.  If  destructive,  it  must  be  gently  but 
firmly  repressed.  If  inactive,  its  little  hands  must  be  made  to 
feel  the  contact  of  toys,  its  sight  stimulated  by  brightly  coloured 
balls,  and  its  hearing  by  music,  or  even  noise.  Instead  of  depriving 
it  of  toys,  let  it  have  an  abundance  to  see  and  handle,  and  even  to 
break.  As  it  gets  older,  encourage  it  to  sit  up,  to  stand,  and  to 
walk,  and  do  all  that  is  possible  to  develop  and  co-ordinate  sensory 
and  motor  activity.  If  the  child  is  to  be  rescued  from  its  solitary 
position,  the  time  so  spent  will  not  be  wasted. 


School  Training  409 

I  think  one  of  the  most  deplorable  things  in  connexion  with 
these  unfortunate  children  is  the  neglect  which  so  often  attaches 
to  their  early  home  hfe.  I  do  not  think  that  this  arises  from 
unkindness,  for  I  have  often  been  struck  by  the  manifest  solicitude 
of  parents  and  all  those  about  them.  It  is  simply  a  matter  of 
sheer  ignorance  as  to  what  to  do  and  how  to  do  it,  but  it  often 
results  in  the  development  of  habits  which  are  ineradicable. 


School  Training. 

Where  the  home  conditions  are  such  that  adequate  training 
cannot  be  obtained,  or  when  such  training  no  longer  suffices  for 
the  needs  of  the  child,  he  should  be  removed  to  a  special  training 
institution.  Usually  this  is  about  the  sixth  or  seventh  year,  but 
in  certain  circumstances  it  may  be  advantageous  to  remove  the 
child  earlier,  whilst  in  others  he  may  stay  at  home  until  a  later 
age  than  this.  The  milder  defectives— t.g.,  mentally  deficient 
children  who  are  not  imbeciles — come  within  the  operation  of  the 
Education  Act  at  seven  years,  and  may  then  be  compelled  to  attend 
special  classes  or  schools. 

School  training  consists  of  more  systematized  methods,  having 
for  their  object  the  development  of  the  sensory,  motor,  intel- 
lectual, and  moral  faculties  of  the  child.  It  is  necessarily  less 
individual  than  the  training  he  has,  or  should  have,  received  at 
home;  but  this  defect  is  more  than  compensated  for  by  the  spirit 
of  emulation  and  of  companionship  which  results  from  association 
with  other  children  like  himself.  Moreover,  although  children 
in  institutions  must  of  necessity  be  taught  in  classes,  it  is  still 
possible,  by  carefully  grading  and  seeing  that  such  classes  are  not 
too  large,  to  ensure  for  each  child  a  sufhcient  amount  of  individual 
attention.  The  regulations  of  the  Board  of  Education  require 
at  least  one  teacher  to  every  twenty  defective  children,  but  in 
lower-grade  aments  the  proportion  of  children  must  be  very  much 
reduced. 

As  we  have  seen  in  previous  chapters,  aments,  with  regard  to 
the  type  of  their  nervous  constitution,  are  divisible  into  two  main 
groups.  On  the  one  hand  there  are  those  who  are  passive,  inert, 
and  markedly  deficient  in  spontaneity ;  on  the  other  there  are  those 
who  are  restless  and  exceedingly  motile,  full  of  "  tricks,"  "  habits," 
and  impulsive  acts,  and  markedly  deficient  in  the  power  of  sustained 


41  o  Treatment  and  Training 

attention.  In  each  of  these  the  training  is  in  accordance  with  the 
general  physiological  principles  which  have  already  been  alluded 
to — namely,  stimulation  through  the  sensory  channels — but  the 
method  is  different  in  the  two  classes.  The  stolid  group,  whose 
main  defect  is  one  of  excitability,  require  stimulation  by  means 
of  romping  games,  musical  drill,  and  vigorous  impressions  of  all 
kinds.  The  restless  and  excitable  class,  on  the  other  hand,  require 
their  excessive  movements  to  be  brought  under  the  control  of  the 
will  by  deliberate  and  systematic  exercises,  such  as  are  comprised 
in  many  of  the  kindergarten  occupations.  But  apart  from  these 
broad  differences,  mentally  deficient  children  differ  enormously 
in  their  power  of  response  as  well  as  in  the  presence  of  particular 
defects  or  irregularities  of  brain  function,  and  it  is  the  duty  of 
the  physician  in  charge  to  make  a  careful  examination  of  each 
child,  and  to  advise  the  teacher  regarding  the  appropriate  method 
of  training.  Individual  teaching  must  still  be  the  keynote,  and 
the  teacher  must  ever  be  on  his  guard  against  neglecting  the 
laggards  for  the  sake  of  those  of  more  promise. 

Teaching  is  an  art  which  cannot  be  taught.  It  must  come  by 
practical  experience  of  the  management  of  children.  The  fol- 
lowing brief  account  simply  aims  at  suggesting  some  of  the  chief 
physiological  methods  upon  which  training  should  proceed.  The 
teacher  with  a  love  for  his  work  and  his  pupils  will  have  no  diffi- 
culty in  adapting,  modifying,  or  extending  these  to  suit  the  needs 
of  any  particular  child,  always  bearing  in  mind  that  the  chief 
requirements  are  the  development  of  what  is  defective  and  the 
elimination  of  what  is  faulty. 

The  Training  of  the  Senses. — The  chief  sensory  organs  through 
which  impressions  reach  the  brain  are  six  in  number  —  namely, 
eye,  ear,  nose,  mouth,  skin,  and  muscle.  Probably  the  training 
of  the  first  and  last  of  these  are  of  most  importance. 

By  means  of  vision,  information  is  gained  regarding  the  colour, 
size,  and  form  of  objects,  and  attention  should  be  given  to  each 
of  these.  It  will  often  be  found  that,  whilst  the  high-grade  ament 
distinguishes  the  primary  colours  readily  enough,  he  is  unable  to 
separate  their  shades;  and  that,  whilst  he  distinguishes  between 
the  form  of  a  triangle,  a  square,  and  a  circle,  he  fails  to  see  any 
difference  between  triangular  or  quadrangular  figures  of  varying 
shape. 

For  teaching  colour  discrimination,  a  very  convenient  apparatus 


School  Training  411 

is  a  series  of  cardboard  tablets,  each  i  inch  square,  and  of  a  different 
shade.  We  may  have  six  or  eight  shades  of  each  of  the  colours 
blue,  red,  green,  yellow,  orange,  and  purple.  It  is  unnecessary 
that  the  child  should  know  the  names,  all  that  he  is  wanted  to  do 
being  to  separate  the  collection  of  tablets  into  heaps  according 
to  their  shade.  Subsequently  he  may  be  taught  their  names. 
Coloured  cubes,  beads,  or  wools  may  be  made  use  of  in  the  same 
way,  and  as  the  child  progresses  he  will  find  great  delight  in  pointing 
out  to  the  teachers  the  different  colours  in  pictures  which  are  shown 
to  him.  Later  on  the  kaleidoscope  may  be  turned  to  profitable 
account  in  the  development  of  colour  discrimination. 

For  cultivating  the  child's  perception  of  form  and  size,  it  is  first 
of  all  necessary  to  draw  his  attention  to  the  coarse  differences 
in  the  many  objects  of  common  use.  After  this  we  may  make 
use  of  a  similar  series  of  tablets  of  various  sizes  and  shapes,  but  of 
uniform  colour,  again  getting  him  to  divide  them  into  heaps. 
"  Size,"  "  form,"  and  "  peg  "  boards,  as  well  as  the  ordinary 
dissected  puzzles  of  the  toy-shops,  not  only  afford  valuable  visual 
training,  but  are  also  of  great  use  in  developing  tactile  sense  and 
in  aiding  muscular  co-ordination. 

The  cultivation  of  the  tactile  and  muscle  senses  is  particularly 
called  for  in  the  case  of  mentally  deficient  children,  since,  in  addi- 
tion to  its  general  educational  value,  these  are  functions  which 
are  absolutely  essential  for  the  proper  performance  of  manual 
occupations,  and  the  future  of  the  ament  must  depend  to  a  very 
great  extent  upon  how  he  can  use  his  hands. 

Sensations  travel  to  the  brain  from  the  muscles  just  the  same 
as  from  eye,  ear,  nose,  etc.,  and  with  a  little  practice  they  may 
be  appreciated  and  compared  with  one  another  in  precisely  the 
same  way.  These  sensations  arise  in  two  ways:  First,  when  a 
muscle  or  series  of  muscles  is  moved;  secondly,  during  the  tension 
of  a  muscle.  Generally  speaking,  impressions  arising  during 
muscular  contractions  are  of  use  in  appreciating  size  and  distance, 
whilst  those  coming  from  muscular  tension  tell  us  of  weight.  Of 
course,  in  the  actions  of  ordinary  Hfe  we  make  use  of  several  senses 
simultaneously,  and  those  from  muscle  are  aided  by  others  from 
skin  and  eye.  In  training,  however,  it  will  usually  be  found 
advantageous  for  the  pupil's  eyes  to  be  kept  closed  during  these 
exercises. 

In  the  inert,   unresponsive  type  of  aments,   we  may  have  to 


412  Treatment  and  Training 

stimulate  the  sensorium  by  passive  movements  of  the  Hmb.s,  or  by 
compelHng  the  hands  to  grasp,  to  feel,  and  to  let  go  objects  of 
different  texture,  temperature,  density,  and  coarseness  or  smooth- 
ness of  surface.  In  the  restless  and  abnormally  motile  type,  con- 
trol, co-ordination,  and  attention  will  be  improved  by  blindfolding 
the  child,  and  getting  him  to  differentiate  between  form  and  size 
tablets  by  passing  his  fingers  round  their  edge.  Many  mild  imbeciles 
will  enter  with  zest  into  the  game  of  guessing  articles  in  a  bag  by 
simply  feeling  them.  Another  excellent  method  is  that  recom- 
mended by  Dr.  Warner.  It  consists  in  accustoming  the  child  to 
differentiate  between  varying  weights  of  shot  contained  in  a  small 
chip-box  held  upon  the  extended  palm.  Miss  Mumbray,  who  has 
had  a  large  practical  experience  of  the  training  of  mentally  defective 
children,  is  in  the  habit  of  directing  her  pupils  to  measure  off  on 
a  sheet  of  paper  a  series  of  prescribed  distances — say  from  ^  inch, 
to  4  or  6  inches.  After  a  little  practice  at  this  they  are  required 
to  draw  lines  of  specified  length  without  the  measure.  In  this 
exercise  the  ocular  as  well  as  the  finger  movements  are  utilized, 
and  the  results  are  not  only  extremely  good  in  themselves,  but 
are  of  the  greatest  value  in  leading  up  to  kindergarten  occupations, 
Sloyd,  and  subsequently  industrial  training. 

It  occasionally  happens  that,  instead  of  sensation  being  dimin- 
ished, it  is  so  much  increased  as  to  become  a  source  of  pain.  The 
hyperaesthetic  hands  must  then  be.  employed  in  rough,  coarse 
work  until  their  sensibility  is  dulled. 

Hearing  is  often  defective  in  aments,  but  many  of  these  children 
are  thought  to  be  deaf  when  the  real  deficiency  is  one  of  spon- 
taneous attention.  The  best  means  of  developing  this  faculty 
is  by  music.  Singing,  musical  drill,  and  the  concerts  of  the  enter- 
tainment-hall, which  should  form  part  of  the  life  of  all  institutions, 
not  only  develop  the  child's  power  of  attention  and  the  range  and 
accuracy  of  his  hearing,  but  are  a  source  of  the  greatest  happiness. 

Where  the  senses  of  taste  and  smell  are  in  need  of  special  culti- 
vation, this  may  be  accomplished  by  placing  upon  the  tongue  such 
substances  as  sugar,  quinine,  salt,  chlorate  of  potash,  soda,  etc.,  or 
by  getting  him  to  sniff  coffee,  cocoa,  snuff,  or  various  essential  oils. 

The  Training  of  Movement. — It  is  impossible  to  overrate  the 
importance  of  this.  The  mentally  deficient  child  who  has  been 
taught  to  walk,  to  speak,  and  to  dress  and  feed  himself,  has  ob- 
viously been  materially  benefited — still  more  so  is  this  the  case. 


School  Training  413 

however,  when  patient  and  systematic  training  has  enabled  him 
to  put  his  hands  to  some  useful  occupation.  But  a  higher  result 
even  has  been  achieved.  Mental  action  and  motor  activity  go 
hand-in-hand,  and  in  the  development  of  muscular  co-ordination 
lies  one  of  our  best  means  of  cultivating  self-control  and  regularity 
of  mental  action. 

The  training  of  movement  in  the  mentally  deficient  resolves 
itself  into  three  processes:  (i)  The  development  of  action,  (2)  its 
co-ordination,  (3)  the  correction  of  motor  anomalies  in  the  form 
of  tricks  and  habits.  These  two  latter  are  accomplished  by  the 
same  means.  Speech  is  also  a  motor  phenomenon,  but  it  will  be 
convenient  to  refer  to  it  separately. 

The  Development  of  Movement. — As  we  have  seen,  a  proportion 
of  aments  are  listless,  torpid,  and  inactive.  They  are  quite  content 
to  sit  still  and  do  nothing,  and  they  even  evince  no  interest  in 
the  games  of  their  companions.  This  condition  is  usually  the 
result  of  a  general  sluggishness  of  the  nervous  system,  but  it  is 
occasionally  caused  by  nervous  exhaustion  due  to  ill-health.  In 
the  latter,  rest,  food,  and  fresh  air  are  necessary ;  in  the  former, 
active  and  vigorous  stimulation  is  required. 

The  only  means  of  stimulating  the  motor  cells  of  such  a  child 
is  through  the  sensory  pathways,  and  these  we  must  endeavour 
to  excite  by  every  possible  device.  The  child  must  be  talked  to; 
his  attention  must  be  attracted  by  brightly  coloured  objects; 
he  may  be  bombarded  with  small  flannel  bags  filled  with  beans, 
until  he  holds  up  his  hands  to  protect  himself,  and  eventually 
assumes  the  offensive;  he  must  be  made  to  listen  to  and  join  in 
the  romping,  singing,  and  drilling  of  the  class;  by  any  means  he 
must  be  made  to  move,  and  until  this  has  been  accomplished, 
systematic  lessons  are  quite  out  of  place. 

The  Co-ordination  of  Movement. — With  the  development  of 
movement,  its  co-ordination  must  be  atended  to.  In  the  healthy 
child  this  takes  place  naturally  through  the  constant  repetition 
induced  by  his  own  initiative.  "  Practice  makes  perfect."  In  the 
ament  the  nervous  discharge  is  irregular,  and  the  harmonious 
adaptation  of  the  motor  response  to  the  sensory  stimuli,  so  that 
an  optimum  result  follows  a  minimum  expenditure,  is  slowly  and 
laboriously  acquired. 

Co-ordination  is  more  readily  developed  in  the  case  of  a  few 
large  muscles,  such  as  those  concerned  in  standing,  walking,  and 


414  Treatment  and  Training 

pushing,  than  in  the  twenty  odd  small  muscles  of  the  hand  or  in 
the  intricate  muscular  apparatus  concerned  in  speech.  Conse- 
quently, the  first  exercises  must  be  directed  towards  teaching  the 
child  to  maintain  a  proper  balance  of  the  body,  to  run  and  to 
walk,  to  push  and  pull,  to  seize,  to  hold,  and  to  let  go,  tolerably 
large  objects.  For  this  purpose  such  exercises  as  mounting  a 
ladder  placed  against  a  wall,  walking  between  the  rungs  of  a 
ladder  placed  fiat  upon  the  ground,  marching  in,  out,  and  over 
various  obstacles  to  the  accompaniment  of  music,  and  accurately 
covering  with  the  feet  a  series  of  footprints  chalked  upon  the  ground, 
as  recommended  by  Seguin,  are  of  the  highest  service. 

At  a  later  stage  finer  movements  of  the  trunk  and  limbs  may 
be  attended  to,  and  here  games  with  a  ball  (such  as  cricket,  foot- 
ball, and  rounders),  free  exercises,  musical  drill,  dumb-bells,  and 
breathing  exercises,  find  their  place.  The  daily  occupations  of 
dressing  and  feeding,  particularly  the  management  of  the  spoon, 
afford  most  valuable  fields  of  instructions.  In  milder  cases,  definite 
"  eye-drill  "  may  be  given. 

Lastly,  manual  dexterity  must  be  developed  by  the  kinder- 
garten occupations,  writing,  drawing,  cutting-out,  paper-folding, 
clay-modelling,  and  the  like.  The  imitation  and  transfer  move- 
ments of  Warner  may  here  be  utilized  in  some  of  the  mildest  cases.* 
Dr.  Warner,  in  fact,  regards  them  as  "  far  more  educative  than 
clay-modelling,  drawing,  and  other  child  occupations."  Theoreti- 
cally this  is  so,  but  it  is  possible  for  an  educational  method,  as  for 
an  article  of  food,  to  be  so  concentrated  as  to  be  unappetizing;  and 
these  exercises  have  the  disadvantage  of  being  somewhat  un- 
interesting, and  of  requiring  an  amount  of  attention  of  which  the 
mentally  defective  child  is  often  incapable.  In  the  training  of 
these  children  interest  is  everything. 

The  correction  of  irregular  movements  in  the  form  of  athetosis, 
"  tricks,"  or  "  habits,"  is  accomplished  by  the  same  methods  as 
those  used  to  develop  co-ordination.  Where  the  abnormality  is 
chiefly  in  the  hands,  the  kindergarten  occupations,  or  in  coarser 
cases  the  peg-board,  will  be  found  of  great  service.  This  latter  is 
a  flat  rectangular  board  drilled  with  holes  of  varying  size,  into 
which   corresponding   pegs   are   to   be    fitted.     Where   the   motor 

*  See  an  interesting  paper  by  Dr.  Warner  on  "  The  Training  of  the  Intelli- 
gence through  the  Hand,"  read  at  the  annual  meeting  of  the  Sloyd  Association, 
1902. 


School  Training  415 

irregularity  concerns  the  face  or  trunk,  facial  and  bodily  gymnastics 
are  indicated. 

The  Training  of  the  Intelligence.— No  means  exist,  or  ever  will 
exist,  by  which  we  can  supply  intelligence  to  the  mentally  defi- 
cient. Each  of  these  children  has  a  certain  capacity  for  develop- 
ment, which  it  is  the  object  of  training  to  educate,  or  "  lead  out," 
and  which  in  the  absence  of  appropriate  training  would  remain 
undeveloped.  To  a  very  considerable  extent  this  is  accomplished, 
as  already  remarked,  b}^  systematic  exercises  stimulating  the 
receptive  and  perceptive  faculties,  and  developing,  controlling, 
and  correcting  the  motor  response.  In.  the  present  section  I  pro- 
pose briefly  to  refer  to  some  of  the  principles  underlying  more 
direct  appeals  to  the  intelligence,  and  here  we  shall  also  consider 
reading,  writing,  and  speech.  These  methods,  of  course,  are  only 
applicable  to  the  milder  degrees  of  mental  deficiency. 

One  of  the  commonest  and  most  important  defects  occurring 
in  these  children  concerns  the  faculty  of  attention.  In  children 
of  the  inert,  placid  type,  spontaneous  attention  is  often  lacking, 
and  the  child  remains  unmoved  and  indifferent,  whatever  happens. 
This  condition  results  from  a  diminished  nervous  excitability, 
and  it  is  remedied  by  a  vigorous  bombardment  of  the  sensorium 
through  every  afferent  pathway.  On  the  other  hand,  the  rest- 
less, unduly  motile,  hyperexcitable  type  are  usually  characterized 
by  a  want  of  voluntary  attention  and  concentration.  Though 
seemingly  so  vivacious,  they  can  settle  down  to  nothing,  and 
almost  every  conscious  sensation  or  every  thought  distracts  them 
from  their  task.  The  only  way  in  which  concentration  and  useful 
work  can  here  be  obtained  is  by  presenting  the  child  with  some- 
thing which  is  interesting.  In  fact,  the  keynote  to  attention  is 
interest,  and  the  pyschological  principles  for  developing  the  power 
of  attention  m.ay  be  expressed  in  the  following  three  maxims :  First, 
the  pupil's  occupations  must  be  those  in  which  he  has  an  interest 
naturally  (and  it  may  be  remarked  that  the  child  whom  nothing 
will  attract  is  in  a  very  parlous  state);  secondly,  his  interest  must 
be  enlarged  by  the  introduction  of  new  occupations  closely  allied 
to,  and  leading  out  of,  those  in  which  he  is  naturally  interested; 
thirdly,  an  artificial  or  derived  interest  must  be  created  for  those 
subjects  which  are  not  attractive  in  themselves,  or,  as  Ribot  says, 
they  must  be  "  rendered  attractive  by  artifice."  Rewards  of 
various  kinds  form  useful  attractions. 


41 6  Treatment  and  Training 

The  process  of  association  is  of  paramount  importance  in  mental 
action.  By  its  means  all  the  varying  impressions  received  through 
the  senses  are  again  connected,  so  as  to  produce  a  complex  picture 
or  a  sequence  of  ideas.  Defective  power  of  association  means  not 
only  crudeness  of  the  individual  mental  images,  but  often  paucity 
of  images  and  ideas  generally.  In  training  this  function,  the 
method  is  the  opposite  of  that  employed  in  teaching  discrimination. 
There  sensations  were  presented  singly,  here  they  are  presented 
simultaneously,  the  law  of  association  being  that  impressions  which 
are  simultaneously  received  by  the  brain  tend  to  acquire  functional 
connexions.  For  example,  let  the  child  handle,  bite,  note  the  form 
and  colour  and  learn  the  name  of,  a  shilling.  The  subsequent 
auditory  sensation  "  shilling  "  wiU  call  up  a  mental  picture  com- 
posed of  its  associates.  Object-lessons  are  also  of  great  value  in 
training  association. 

Memory  is  largely  dependent  upon  the  power  of  association, 
and  in  proportion  as  we  develop  this  so  we  cultivate  memory. 
It  is  very  useful  to  encourage  the  child's  power  of  recall  by  getting 
him  to  give  an  account  of  the  things  seen  or  done  upon  returning 
from  a  walk  or  at  the  end  of  the  day.  Exercises  in  repeating 
poetry,  quotations,  and  the  like,  help  the  child  to  remember  the 
particular  things  repeated,  but  it  is  a  mistake  to  imagine  that 
they  do  anything  towards  cultivating  the  "  faculty  "  of  memory 
in  general. 

The  capacity  for  forming  thoughts,  judging  and  reasoning,  is  best 
stimulated  and  encouraged  by  individual  contact  with  that  teacher 
who  knows  how  to  present  to  the  deficient  mind  in  an  easily  assimi- 
lable form  the  simple  facts  of  nature  and  everyday  life.  What  are 
called  object-lessons  are  here  of  the  greatest  value,  but  their  value 
consists,  not  so  much  in  the  matter,  as  the  manner  in  which  they 
are  presented.  A  good  teacher  will  know  how  to  turn  almost 
anything  to  account,  although  most  benefit  wiU  result  from  those 
objects  in  which  the  child  has  a  natural  interest.  It  is  of  the 
highest  importance  that  he  should  be  carefull}^  questioned  and 
encouraged  to  ask  questions,  and  the  teacher  must  ensure  that 
everything  is  in  the  concrete,  and  that  the  ideas  presented  to  the 
child  have  their  visible,  tangible,  and  material  counterparts. 

Speech. — The  mechanism  concerned  in  speech,  and  the  chief 
anomalies  present  in  the  mentally  deficient,  have  been  described 
in  a  previous  chapter.     In  some  of  these  children  speech  is  absent 


School  Training  417 

in  consequence  of  a  lesion  of  the  motor  centre,  and  these  cases  are 
probably  incurable.  In  others  intractable  deafness  is  the  cause, 
and  then  occasionally  (but  very  occasionally  where  mental  defect 
is  present)  speech  may  be  acquired  by  means  of  lip  imitation. 
Other  children  of  the  lower  grades  apparently  never  speak  because 
they  have  no  ideas  to  express,  or  because  it  is  easier  for  them  to 
voice  their  feelings  by  grunts,  screeches,  and  inarticulate  noises. 
In  the  majority  of  the  milder  aments,  however,  there  is  some  ability 
to  speak,  but  speech  is  faulty  and  imperfect  in  consequence  of 
conditions  which,  if  not  entirely  curable,  are  at  least  in  great  part 
ameliorable  by  treatment. 

There  are  two  chief  causes  of  these  defects:  Firstly,  anatomical 
abnormalities  of  the  end-organs  concerned  in  speech-production 
or  in  the  perception  of  sounds;  secondly,  deficient  muscular  action 
and  inco-ordination.  The  former  of  these  consist  of  adenoids, 
enlarged  tonsils,  cleft  palate,  suppurating  otitis,  etc.,  and  are 
chiefly  responsible  for  thickness,  indistinctness,  and  alterations 
of  tone.  These  must  be  attended  to  by  the  surgeon  before  sys- 
tematic instruction  is  attempted.  Muscular  inco-ordination  gives 
rise  to  stammering,  stuttering,  inability  to  pronounce  certain 
consonants,  and  the  habit  of  substituting  easy  sounds  for  those 
which  are  difficult.  The  essence  of  speech-training  consists  in 
discovering  the  nature  and  cause  of  the  particular  faults,  and 
remedying  them  by  the  appropriate  methods. 

Where  muscular  action  is  defective,  which  may  be  but  part  of 
a  general  inertia  as  seen  in  the  stolid  type  of  aments,  it  may  be 
cultivated  by  encouraging  the  child  to  make  use  of  his  lips  and 
tongue  in  blowing  a  toy  trumpet  or  whistle.  But  in  cases  where 
muscular  inco-ordination  is  the  chief  fault  this  is  unnecessary, 
although  such  children,  including  stutterers  and  stammerers,  will 
be  benefited  by  a  course  of  lip  and  tongue  gymnastics  and  breathing 
exercises.  In  many  cases  where  the  faculty  of  speech  lingers 
music  is  a  great  help.  As  Dr.  Shuttleworth  says,  "  Such  children 
will  frequently  hum  tunes  that  take  their  fancy  before  they  are 
able  to  articulate  words;  but  if  attractive  tunes  set  to  words  con- 
taining repetitions  of  simple  sounds  (such  as  the  '  Ba-ba,  black 
sheep,'  of  our  old  nursery  rhymes)  are  constantly  repeated  to  them, 
the  probability  is  that,  after  a  time,  first  one  word  and  then  another 
will  be  taken  up  by  the  pupil,  tiU  the  rhyme  as  well  as  the  tune  is 
known." 

27 


41 8  Treatment  and  Training 

In  cases  of  slurring,  word-clipping,  and  consonantal  defects, 
the  fault  generally  lies  in  a  want  of  synergic  action,  and  the  only 
remedy  is  for  the  teacher  to  demonstrate  with  his  own  articulatory 
apparatus  how  the  defective  sound  should  be  produced,  until  the 
child  is  able  to  imitate  it.  This  requires  considerable  patience  of 
both  teacher  and  pupil,  and  it  is  essential  that  the  latter  should 
carefully  watch  the  teacher's  mouth  and  lips  the  while.  It  is 
useful  to  remember  that  many  consonants  which  cannot  be  pro- 
nounced at  the  beginning  of  a  word  can  be  produced  in  the  middle,, 
and  thus  the  desired  sound  may  often  be  forthcoming  if  it  is  pre- 
ceded by  one  the  child  knows. 

Writing  naturally  follows  speech,  and  the  first  steps  consist  in 
the  making  of  strokes  upon  the  ruled  slate.  Much  of  the  difhculty 
experienced  by  defective  children  is  the  result  of  imperfect  co- 
ordination, which  only  practice  and  patience  will  overcome,  and 
many  of  the  imbeciles  never  do  overcome  it.  In  any  case  it  will 
be  necessary  for  the  teacher  to  guide  the  child's  hand  in  his  initial 
attempts  at  making  vertical,  horizontal,  and  oblique  lines,  and 
this  may  have  to  be  kept  up  for  weeks.  Some  children  learn  to 
make  rough  drawings  more  easily  than  to  write,  probably  because 
the  task  is  more  interesting,  and  the  practice  of  tracing  pictures 
which  underlie  a  piece  of  framed  frosted  glass  is  sometimes  of 
assistance  to  writing.  The  imbecile  who,  after  repeated  coaxing, 
is  unable  to  make  any  attempt  at  tracing,  and  whose  only  result 
is  a  meaningless  scribble,  is  probably  incapable  of  being  taught. 

Reading.— Few  imbeciles  acquire  the  power  of  reading,  but  the 
majority  of  the  feeble-minded,  as  a  result  of  years  of  training,  learn 
to  read  books  of  simple  words  and  short  sentences.  Many  of  the 
higher  types,  indeed,  become  good  readers.  Probably  the  best 
method  of  teaching  is  the  word  method,  in  which  short  words  are 
read  "  at  sight  "  before  any  attempt  is  made  to  teach  the  alphabet; 
but  time  and  patience  rather  than  any  particular  method  are  the 
chief  essenticds. 

Arithmetic. — Number  is  usually  a  great  stumbling-block  to 
aments,  although  there  are  some  feeble-minded  persons  who  have 
an  extraordinary  affection  for  dates,  and  occasionally  ability  to 
calculate.  The  reason  of  their  difficulty  seems  to  be  their  in- 
ability to  appreciate  the  abstract,  and  it  is  essential,  in  teaching 
number,  that  concrete  examples  should  always  be  made  use  of. 
This  is  done  by  means  of  beads,  counters,  the  abacus,  or  by  gradu- 


Industrial  Training  419 

ated  wooden  rods.  The  cultivation  of  the  child's  faculty  of  dis- 
criminating siz6  and  weight  through  his  muscle  sense,  in  the  manner 
previously  described,  is  a  useful  prelude  to  teaching  him  number. 
An  excellent  form  of  concrete  instruction  is  afforded  by  the  "  shop 
lesson."  Having  mastered  the  principles  of  addition  and  subtrac- 
tion by  means  of  actual  objects,  the  less  defective  pupils  may  be 
initiated  into  the  mystery  of  the  numerical  symbols,  but  progress 
with  these  will  usually  be  very  laborious. 


Industrial  Training. 

Hitherto  we  have  been  concerned  with  the  chief  means  by  which 
the  intellectual  and  nervous  functions  of  the  mentally  deficient 
child  m-ay  be  stimulated  and  brought  into  orderly  use — with  educa- 
tion in  its  general  sense.  We  now  pass  to  technical  instruction. 
It  is  not  to  be  assumed,  however,  that  the  two  are  really  separate, 
or  that  this  latter  has  no  educational  value.  On  the  contrary, 
technical  or  industrial  training  is  not  only  a  continuation,  and  the 
natural  outcome,  of  many  occupations  and  exercises  which  have 
formed  part  of  the  general  training,  but  in  itself  it  is  of  distinct 
educational  value.  It  is  a  well-recognized  fact  that  the  mentally 
deficient  child  learns  more  with  his  hands  than  with  his  head; 
whilst  his  future  is  far  more  a  matter  of  manual  than  of  mental 
dexterity.  Industrial  and  technical  training,  therefore,  is  at  once 
an  educational  factor  of  considerable  importance,  as  well  as  the 
only  means  of  turning  these  unfortunate  children  to  practical 
account.  It  has  been  shown  that,  as  a  result  of  this  training,  a 
considerable  number  of  the  milder  aments  become  capable  of  re- 
munerative work;  and  even  where  the  social  position  is  such  that 
this  is  unnecessary,  it  is  still  of  the  greatest  use  in  providing  them 
with  employment.  The  teaching  of  a  definite  occupation,  then, 
should  never  be  omitted,  and  should,  if  possible,  be  begun  during 
childhood  or  adolescence.  One  cannot  but  feel  that  in  many 
instances  there  is  a  tendency  to  allow  school-training  to  go  beyond 
its  real  purpose — that  of  cultivating  intellectual  and  nervous  action 
generally — and  to  make  it  too  scholastic. 

The  nature  of  the  industrial  training  must  be  determined  by  the 
particular  characteristics  of  the  individual,  regard  being  paid,  of 
course,  to  sex  and  social  position,  and  to  the  probable  environment 
in  after-life.     Where  possible,   an  outdoor  occupation  should  be 


420  Treatment  and  Training 

selected,  and  particularly  so  in  the  case  of  those  whose  coarsely 
formed  hands  stand  in  the  way  of  any  manual  dexterity — such,  for 
instance,  as  the  Mongolians.  But  care  must  be  taken  to  protect 
those  so  engaged  against  the  inclemency  of  the  weather,  and  it 
must  be  remembered  that  there  may  be  many  days  when  this  will 
absolutely  prevent  outdoor  work.  Gardening,  whether  of  flowers, 
fruit,  or  market  produce,  is  particularly  suitable,  and  the  child's 
taste  for  this  may  be  developed,  as  well  as  a  certain  amount  of 
useful  information  imparted,  by  practical  object-lessons  in  growing 
seeds,  plants,  etc.,  in  the  schoolroom.  The  strong  and  sturdy  type 
may  be  usefully  employed  in  the  dairy  or  on  the  farm. 

Where  regular  outdoor  work  is  impossible,  either  on  account  of 
the  physical  condition  of  the  patient  or  for  lack  of  accommodation, 
there  are  many  useful  and  remunerative  indoor  occupations  which 
may  be  taught.  Amongst  these  may  be  mentioned,  for  males, 
boot-making,  tailoring,  carpentry,  basket-weaving,  mat  and  brush 
making,  chair  -  caning,  bookbinding,  and  suchlike.  For  females 
there  are  cookery,  laundry  work,  dressmaking,  hand  and  machine 
sewing,  knitting,  and  even  embroidery  and  fine-art  needlework. 
In  all  well-equipped  institutions  a  considerable  amount  of  the 
making,  mending,  and  general  domestic  work  of  the  establishment 
— even  the  printing — is  performed  by  the  inmates,  under  super- 
vision. Instruction  in  these  various  occupations  is,  of  course,  given 
by  skilled  master  hands. 

Moral  Training. 

The  training  of  the  child's  moral  or  ethical  sense  is  by  no  means 
the  least  important  of  the  teacher's  duties;  indeed,  if  this  is  not 
carefuUy  attended  to,  the  education  of  his  intellect  may  simply 
result  in  an  increased  power  for  iU,  and  cause  him  to  be,  not  merely 
useless,  but  actually  dangerous  to  society.  Moral  education,  there- 
fore, forms  an  essential  part  of  the  home  and  school  training  of  the 
mentally  deficient  child.  It  has  for  its  general  object  the  repres- 
sion of  antisocial  tendencies  and  the  inculcation  of  habits  or  prin- 
ciples which  will  enable  the  child  to  adapt  his  conduct  to  the  laws 
of  his  society  and  the  well-being  of  his  fellow-creatures.  It  is 
entirely  removed  from,  and,  from  the  physician's  standpoint,  is  of 
greater  importance  than,  religious  education.  If  the  condition  of 
the  child  permits,  the  elementary  principles  of  a  religious  doctrine 
may  be  added,  and  in  some  cases  Christian  ideals  may  exert  a 
considerable  effect  upon  the  moral  behaviour.     The  question  of 


Moral  Training  421 

religious  education,  however,  is  the  domain  of  the  ecclesiastic,  and 
bej'ond  the  scope  of  this  work. 

The  bulk  of  aments  are  rather  amoral  than  immoral,  and  their 
defect  of  ethical  sense  stands  in  the  same  relationship  to  that  of 
the  normal  child  as  does  their  defect  of  general  intelligence,  requir- 
ing also  special  means  for  its  development.  There  are,  however, 
three  types  specially  prone  to  the  commission  of  immoral  acts,  and 
the  training  of  these  must  be  the  object  of  particular  care. 

These  are,  first,  those  who  are  readily  induced  to  commit  anti- 
social acts,  at  the  instigation  of  unscrupulous  persons,  because  of 
their  extremely  "  facile  "  disposition.  Impressionable,  susceptible, 
and  readily  swayed,  utterly  incapable  of  withstanding  the  sugges- 
tions, good  or  bad,  of  their  companions,  the  only  safeguard  is  to 
keep  them  away  from  temptation,  and  to  ensure  that  their  social 
atmosphere  shall  be  good.  It  is  possible  that  in  course  of  time 
this  atmosphere  may  to  some  extent  lead  to  the  formation  of  an 
active  moral  sense,  and  that  the  persistent  inculcation  of  moral 
precepts  may  make  impressions  capable  of  influencing  their  con- 
duct; but,  in  my  opinion,  this  can  never  be  relied  upon,  and  the 
only  safe  course  with  regard  to  this  class  is  to  keep  them  under 
permanent  supervision.  They  are  simple  and  confiding  beings,  and 
many  of  them  are  industrious  workers. 

The  second  group  consists  of  those  persons  whose  nervous  con- 
stitution is  so  unstable  and  explosive  that  the  most  trifling  occur- 
rence serves  to  produce  a  violent  storm.  In  this  they  will  commit 
a  grave  breach  of  discipline,  an  offence  against  law  and  society, 
or  even  a  serious  crime.  The  attacks  in  many  ways  resemble  the 
motor  storms  of  the  epileptic;  in  fact,  the  condition  may  well  be 
termed  one  of  psychic  epilepsy.  In  such  cases  some  degree  of 
control  is  frequently  acquired  as  the  result  of  regular  occupation, 
careful  supervision,  and  firm  discipline.  Medicinal  treatment  in 
the  form  of  the  bromides  is  often  also  a  valuable  adjunct,  and  by 
these  means  considerable  improvement,  or  even  cure,  may  be 
brought  about. 

The  third  group  consists  of  those  lacking  in  moral  sense.  In 
these  there  seems  to  be  an  absolutely  ineradicable  propensity  to 
the  commission  of  every  kind  of  offence,  and  these  persons  will 
lie,  steal,  burn,  destroy,  and  assault,  without  being  influenced  in 
the  slightest  by  persuasion,  threat,  or  punishment  of  any  descrip- 
tion. Again  and  again  have  I  known  the  offence  repeated  almost 
whilst  the  words  of  contrition  were  hot  upon  the  tongue.     I  believe 


422  Treatment  and  Training 

that  this  condition  is  practically  incurable,  and  that  the  only  safe- 
guard lies  in  strict  and  permanent  detention. 

Passing  now  to  the  ordinary  type,  in  which  there  is  neither  a 
specially  facile  disposition,  a  predisposition  to  emotional  storms, 
nor  deeply  ingrained  immoral  and  criminal  tendencies,  we  have 
to  consider  the  manner  in  which  the  latent  ethical  sense  may  be 
sufficiently  developed  to  lead  the  child  to  shape  his  conduct  in 
accordance  with  the  manners  and  customs  of  good  society.  If 
this  be  not  so  developed,  it  is  tolerably  certain  that  the  age  of 
puberty,  if  not  earlier,  will  see  the  assertion  of  many  animal  in- 
stincts which  the  weakened  capacity  of  control  will  be  powerless 
to  overcome. 

It  was  stated  by  John  Stuart  Mill  that  the  foundation  of  the 
moral  principle  lies  in  utility.  The  mentally  normal  child  may 
be  taught  to  be  moral  through  a  gradual  recognition  of  this.  By 
being  made  to  suffer  the  natural  consequences  of  his  own  breaches 
of  discipline,  he  is  gradually  brought,  through  his  intellect,  to 
appreciate  that  virtue  is  attended  with  pleasurable,  and  vice  and 
wrongdoing  with  unpleasant,  consequences.  To  a  certain  extent 
this  may  be  made  use  of  in  the  mentally  deficient  child,  but  his 
defect  is  often  such  that  he  cannot  be  made  to  appreciate  the 
natural  consequences,  the  utility  or  futility,  of  every  act  he  com- 
mits, and  this  result  can  only  be  attained  by  a  system  of  arbitrary 
rewards  and  punishments. 

There  are  many  rewards  for  good  conduct  which  appeal  to  these 
children.  In  the  lower  types  the  promise  of  a  toy,  a  sweetmeat, 
or  some  little  treat  in  the  shape  of  an  entertainment,  will  often 
prove  a  useful  incentive  to  good  behaviour.  Many  mentally  de- 
fective school-children  attach  great  value  to  the  little  cardboard 
medal  pinned  upon  their  breast  by  the  teacher,  and  at  a  later  stage 
the  commendation  alone  of  the  instructor  to  whom  they  have 
grown  attached  will  suffice.  Similarly  with  punishment.  The 
deprivation  of  some  favourite  article  of  food,  such  as  the  with- 
holding of  pudding  for  dinner,  the  denial  of  the  entertainment 
which  the  child's  companions  are  allowed  to  enjoy,  the  reproof  of 
the  teacher — all  these  may  be  made  use  of  to  impress  upon  the 
child  that  wrongdoing  is  unpleasant,  and  that  it  is  wisdom  to  be 
good. 

It  is  very  important  that  the  whole  demeanour  of  the  teacher 
should  be  kind  and  sympathetic,  gentle  but  firm,  and  that  all 
petting  and  spoiling  should  be  rigorously  avoided.     Approbation, 


Moral  Training  423 

if  earned,  should  be  bestowed  ungrudging^,  and  will  be  found  a 
powerful  incentive  to  further  progress  and  factor  in  moral  training. 
Disapprobation,  if  consistently  expressed,  is  often  equally  efficacious 
as  a  deterrent. 

With  regard  to  the  infliction  of  corporal  punishment  opinions 
are  somewhat  divergent.  My  own  feeling  is  that  it  should  be 
avoided  wherever  possible.  But  in  cases  of  wilful  and  flagrant 
breaches  of  discipline  or  open  defiance  of  authority  it  is  not  only 
justifiable,  but  beneficial;  in  fact,  it  is  often  the  only  means  by 
which  the  child  may  be  taught  that  respect  for  others  which  is  the 
essence  of  morality. 

In  the  task  of  implanting  good  habits  and  the  developing  of  the 
ethical  sense,  the  faculty  of  imitation,  often  so  marked  in  these 
children,  must  never  be  lost  sight  of,  since  it  may  readily  be  turned 
to  good  or  bad  account.  It  is  extraordinary  how  mild  and  gentle 
girls,  brought  up  in  an  atmosphere  of  refinement  and  care,  will 
suddenly,  and  upon  the  slightest  provocation,  give  vent  to  a  torrent 
of  the  most  disgusting  and  obscene  abuse  which  they  may  have 
heard  by  chance  on  some  solitary  occasion.  It  is  of  the  highest 
importance  that  the  surroundings  and  the  tone  of  mentally  deficient 
persons  should  be  well  ordered  from  the  very  beginning,  and  there 
is  no  doubt  that  the  home  environment  of  early  life  exercises  a 
most  potent  influence  in  after-years.  We  cannot  expect  these 
children  to  become  affectionate,  S57mpathetic,  and  generous  unless 
these  qualities  are  evident  in  the  lives  of  those  about  them,  and  a 
rigorous  censorship  of  the  entire  social  atmosphere,  even  with 
regard  to  pictures  and  entertainments,  is  an  absolute  necessity. 
If  we  are  to  ensure  truthfulness,  honesty,  and  uprightness,  it  is 
essential  that  parents,  teachers,  and  physician  should  be  truthful, 
just,  and  straightforward  in  all  their  dealings  with  these  children. 
Reward  and  punishment  must  be  deliberate,  and  apportioned  in 
such  a  manner  as  not  only  to  fit  the  crime,  but  to  establish  its 
relationship  in  the  mind  of  the  child.  Otherwise  it  will  result  in 
more  harm  than  good,  and  will  inevitably  lead  to  a  complete 
alienation  of  confidence  and  affection.  By  the  judicious  imposi- 
tion of  punishment  or  reward,  which  the  child  recognizes  as  being 
related  to  his  fault  or  virtue,  we  shall  be  in  no  danger  of  losing  his 
love  and  affection  or  violating  his  sense  of  justice.  We  shall 
develop,  rather  than  perplex,  his  reasoning  power,  and  we  shall 
cultivate  his  moral  sense  and  control  just  as  we  developed  his 
intellectual  capacity. 


CHAPTER  XX 
THE  LAW  OF  ENGLAND  CONCERNING  AMENTIA 

Prior  to  the  year  1913  the  laws  of  England  regarding  the  care 
and  control  of  persons  suffering  from  amentia  were  far  from  satis- 
factory. Idiots  and  imbeciles,  it  is  true,  were  provided  for  by  two 
statutes — namely,  the  Idiots  Act  of  1886,  and  the  Lunacy  Act  of 
1890.  The  education  of  mentally  defective  children  was  also  sanc- 
tioned by  the  Defective  and  Epileptic  Children  Act  of  1899;  but 
the  largest  and  most  important  class  of  all — that  of  the  adult  feeble- 
minded— was  not  recognized,  and  the  absence  of  any  legalized 
provision  for  their  systematic  care  and  control  caused  no  little 
hardship  to  the  defectives  themselves,  besides  being  a  source  of 
very  considerable  danger  to  the  welfare  of  the  community.  It  was, 
in  fact,  to  a  great  extent  the  recognition  of  this  which  led  to  the 
appointment  of  the  Royal  Commission  of  1904,  "  to  consider  and 
report  Upon  the  existing  methods  of  dealing  with  idiots  and  epi- 
leptics, and  with  imbecile,  feeble-minded,  or  defective  persons  not 
certified  under  the  lunacy  laws." 

It  is  extremely  gratifying  to  find  that  the  labours  of  this  Com- 
mission have  now  resulted  in  an  Act  of  Parliament,  and  in  the 
Mental  Deficiency  Act  of  1913  we  have  a  consolidated  measure 
which  contains  provisions  for  the  adequate  supervision  of  a  con- 
siderable proportion  of  the  mentally  defective  population.  I  say 
a  considerable  proportion,  because  it  is  necessary  to  point  out  that 
the  provisions  of  the  Act  do  not  extend  to  mental  defect  as  such, 
but  only  to  those  aments  who  fulfil  certain  conditions.  Since  the 
Mental  Deficiency  Act  contains  clauses  defining  the  duties  of 
education  authorities  in  regard  to  this  class,  also  clauses  regulating 
transfers  from  lunatic  asylums  to  institutions  for  defectives,  and 
vice  versa,  and  since  it  repeals  the  Idiots  Act,  it  has  become  the 
chief  measure  concerning  aments,  and  it  is  therefore  necessary  to 
give  a  short  summary  of  its  main  provisions: 

424 


The  Mental  Deficiency  Act,   191 3  425 

THE  MENTAL  DEFICIENCY  ACT,  1913.*    [3  &  4  Geo.  V.] 

An  Act  to  make  Further  and  Better  Provision  for  the  Care  of  Feeble- 
minded and  other  Mentally  Defective  Persons,  and  to  amend  the 
Lunacy  Acts. 

(To  come  into  operation  on  April  i,  1914,  and  not  extending  to 
Scotland  or  Ireland.) 

Defectives  within  the  Meaning  of  the  Act. 

The  classes  of  persons  who  are  defectives  within  the  meaning  of 
this  Act  are  four — namely,  Idiots,  Imbeciles,  Feeble-minded  Per  sons  > 
and  Moral  Imbeciles.     [Clause  i.] 

The  legal  definition  of  each  of  these  has  already  been  given  on 
pp.  91-94. 

Circumstances  rendering  Defectives  subject  to  be  dealt  with. 

A  person  who  is  a  defective  may  be  dealt  with  under  this  Act  by 
being  sent  to,  or  placed  in,  an  institution  for  defectives,  or  placed 
under  guardianship — 

(A)  At  the  instance  of  his  parent  or  guardian,  if  he  is  an  idiot  or 
imbecile,  or  at  the  instance  of  his  parent  if  he  is  a  feeble-minded 
person  or  moral  imbecile  and  is  under  the  age  of  twenty-one;  or 

(B)  If  in  addition  to  being  a  defective  he  is  a  person — 

(i.)  Who  is  found  neglected,  abandoned,  or  without  visible  means 
of  support,  or  cruelly  treated;  or 

(ii.)  Who  is  found  guilty  of  any  criminal  offence,  or  who  is  ordered, 
or  found  liable  to  be  ordered,  to  be  sent'  to  a  certified  industrial 
school;  or 

(iii.)  Who  is  undergoing  imprisonment  (except  imprisonment 
under  civil  process),  or  penal  servitude,  or  is  undergoing  detention 
in  a  place  of  detention  by  order  of  a  court,  or  in  a  reformatory  or 
industrial  school,  or  in  an  inebriate  reformatory,  or  who  is  detained 
in  an  institution  for  lunatics  or  a  criminal  lunatic  asylum;  or 

(iv.)  Who  is  an  habitual  drunkard  within  the  meaning  of  the 
Inebriates  Acts,  1879  to  1900;  or 

(v.)  In  whose  case  such  notice  has  been  given  by  the  local  educa- 
tion authority  as  hereinafter  mentioned;  or 

*  Printed  by  Eyre  and  Spottiswoode,  Ltd.,  and  to  be  purchased  from 
Wyman  and  Sons,  Ltd.,  Fetter  Lane,  London,  E.G. 


426     The  Law  of  England  Concerning   Amentia 

(vi.)  Who  is  in  receipt  of  poor  relief  at  the  time  of  giving  birth 
to  an  illegitimate  child  or  when  pregnant  of  such  child.    [CI.  2  (i).] 


Methods  of  Procedure. 

The  methods  of  procedure  in  the  case  of  the  above  persons  are 
as  follows : 

A.  By  Parent  or  Guardian. — If  the  patient  is  an  idiot  or  imbecile, 
the  parent  or  guardian  may  place  him  in  an  institution  or  under 
guardianship  upon  certificates  in  the  prescribed  form  signed  by 
two  duly  qualified  medical  practitioners,  one  of  whom  must  be  a 
medical  practitioner  approved  for  the  purpose  by  the  local  authority 
or  the  Board  of  Control.     [CI.  3.] 

If  he  is  not  an  idiot  or  imbecile,  and  is  under  the  age  of  twenty-one, 
his  parent  may  place  him  in  an  institution  or  under  guardianship; 
but  in  that  case  the  two  medical  certificates  must  be  supplemented 
by  the  certificate  of  a  judicial  authority — i.e.,  a  County  Court 
Judge,  a  Stipendiary  Magistrate,  or  a  specially  appointed  Justice — 
signed  after  such  inquiry  as  he  shall  think  fit,  and  by  a  statement 
of  particulars  signed  by  the  parent  or  guardian.     [CI.  3  (i).] 

A  defective  coming  within  any  of  the  categories  (i.)  to  (vi.) 
enumerated  above  may  be  dealt  with  as  follows : 

B.  By  Petition  to  a  Judicial  Authority  from  any  Relative  or 
Friend,  or  from  an  Authorized  Officer  of  the  Local  Authority.- — Such 
petition  must  be  accompanied  by  two  medical  certificates,  one  of 
which  must  be  signed  by  a  medical  practitioner  approved  for  the 
purpose  by  the  local  authority  or  Board,  or  a  certificate  that  a 
medical  examination  was  impracticable,  and  by  a  statutory  declara- 
tion signed  by  the  petitioner  and  by  at  least  one  other  person  (who 
may  be  one  of  the  medical  signatories)  stating — {a)  that  the  patient 
is  a  defective  within  the  meaning  of  the  Act,  and  the  class  of  defec- 
tives to  which  he  is  alleged  to  belong;  {b)  that  he  is  subject  to  be 
dealt  with  under  the  Act,  and  the  circumstances  which  render  him 
so  subject;  (c)  whether  or  not  a  petition  under  this  Act  or  under 
the  Lunacy  Act  has  previously  been  presented  concerning  the 
patient,  and  if  such  has  been  presented,  the  date  thereof  and  the 
result  of  the  proceedings  thereon;  and  [d)  if  the  petition  is  accom- 
panied by  a  certificate  that  a  medical  examination  was  impracticable, 
the  circumstances  which  rendered  it  impracticable.     [CI.  5  (i),  (2).] 

If  the  petition  is  not  presented  by  a  relative  or  by  an  officer  of 


Methods  of  Procedure  427 

"the  local  authority,  it  must  contain  a  statement  of  the  reasons 
why  it  is  not  so  presented,  and  of  the  connexion  of  the  petitioner 
with  the  person  to  whom  the  petition  relates,  and  the  circumstances 
Tinder  which  he  presents  it.     [CI.  5  (3).] 

Upon  the  presentation  of  the  petition  and  the  aforesaid  docu- 
ments the  judicial  authority  shall  either  visit  the  alleged  defective 
person  or  summon  him  to  appear  before  him.     [CI.  6  (i).] 

Any  proceedings  before  the  judicial  authority  may  be  conducted 
in  private  at  his  discretion,  and  shall  be  so  conducted  upon  the 
■desire  of  the  alleged  defective.     [CI.  6  (2).] 

If  the  judicial  authority  is  satisfied  that  the  person  is  a  defective, 
and  subject  to  be  dealt  with  under  the  Act,  he  may  then,  if  he 
thinks  it  desirable  to  do  so,  make  an  order  for  his  retention,  in  an 
institution  the  managers  of  which  are  willing  to  receive  him,  or 
he  may  appoint  a  suitable  person  to  be  his  guardian.  Provided 
that  where  the  petition  is  not  presented  by  the  parent  or  guardian, 
no  order  shall  be  made  without  the  consent  in  writing  of  such  parent 
or  guardian,  unless  the  judicial  authority  is  satisfied  that  such 
consent  is  unreasonably  withheld,  or  that  the  parent  or  guardian 
cannot  be  found.  If  the  judicial  authority  is  not  satisfied  that  the 
alleged  defective  comes  within  the  Act,  or  that  it  is  desirable  in 
the  interests  of  the  patient  that  an  order  should  be  made,  he  may 
adjourn  the  case  for  a  period  not  exceeding  fourteen  days  for 
further  information,  he  may  order  that  the  patient  shall  submit 
himself  to  medical  examination,  or  he  may  dismiss  the  petition. 
Unless  the  petition  is  dismissed,  the  judicial  authority  must  order 
a  medical  examination  in  any  case  where  the  petition  was  accom- 
panied bv  a  certificate  that  a  medical  examination  was  imprac- 
ticable.   "[CI.  3  (3),  (4).] 

C.  By  Order  of  the  Court. — On  the  conviction  by  a  court  of  com- 
petent jurisdiction  of  any  person  of  any  criminal  offence  punishable 
with  penal  servitude  or  imprisonment,  or  on  a  child  brought  before 
a  court  under  Section  58  of  the  Children  Act,  1908,  being  found 
liable  to  be  sent  to  an  industrial  school,  the  court,  if  satisfied  on 
medical  evidence  that  he  is  a  defective  within  the  meaning  of  this 
Act,  may  either  postpone  passing  sentence  or  making  an  order  for 
committal  to  an  industrial  school,  and — (i)  direct  that  a  petition 
be  presented  to  a  judicial  authority,  or  (2)  may  make  an  order 
similar  to,  and  which  shall  have  the  same  effect  as,  that  made  by 
a  judicial  authority.     [CI.  8  (i).] 


428     The   Law  of  England   Concerning   Amentia 

D.  By  Order  of  the  Home  Secretary. — Where  the  Secretary  of 
State  is  satisfied  from  the  certificate  of  two  duly  qualified  medical 
practitioners  that  any  person  who  is  undergoing  imprisonment 
(except  imprisonment  under  civil  process)  or  penal  servitude,  or  is 
undergoing  detention  in  a  place  of  detention  by  order  of  a  court, 
or  in  a  reformatory  or  industrial  school  or  in  an  inebriate  reforma- 
tory, or  who  is  detained  in  a  criminal  lunatic  asylum,  is  a  defective^ 
the  Secretary  of  State  may  order  that  he  be  transferred  therefrom 
and  sent  to  an  institution  for  defectives,  the  managers  of  which  are 
willing  to  receive  him,  or  that  he  be  placed  under  guardianship, 
and  any  order  so  made  shall  have  the  like  effect  as  if  it  had  been 
made  by  a  judicial  authority  on  petition  under  this  Act.     [CI.  9.] 

Effect  and  Duration  of  Orders. 

The  effect  and  duration  of  orders  made  as  above  is  as  follows : 

(i)  If  the  order  is  for  the  defective  to  he  sent  to  an  institution,  it 
authorizes  his  conveyance  thereto  and  his  reception  therein  at  any 
time  within  fourteen  days  after  the  date  of  the  order.     [CI.  10  (i).] 

The  order  expires  at  the  end  of  one  year,  but  may  be  continued 
for  a  year,  and  afterwards  for  successive  periods  of  five  years,  if 
the  Board  of  Control,  after  due  consideration,  are  of  opinion  that 
such  is  desirable  in  the  interests  of  the  defective  person,  and  make 
an  order  for  the  purpose.     [CI.  11  (i),  (2).] 

Where  a  defective  has  been  placed  by  his  parent  or  guardian  in 
an  institution  or  under  guardianship,  the  parent  or  guardian  may 
withdraw  him  at  any  time  on  giving  notice  in  writing  to  the  Board 
of  Control,  unless  the  Board,  after  considering  what  means  of  care 
and  supervision  would  be  available  if  he  were  discharged,  deter- 
mine within  fourteen  days  that  his  own  interest  requires  his  further 
detention,  and  in  that  case  no  further  notice  by  the  parent  or 
guardian  shall  be  allowed  till  after  the  expiration  of  six  months 
from  the  previous  notice.     [CI.  12  (i).] 

The  managers  of  any  certified  institution,  or  house,  or  any  ap- 
proved house,  may  discharge  any  defective  placed  there  by  his 
parent  or  guardian  on  giving  one  month's  notice  to  the  Board  and 
to  the  parent  or  guardian  of  the  defective,  if  known.      [CI.  12  (3).] 

(2)  If  the  order  is  for  the  defective  person  to  he  placed  under  guardian- 
ship, it  confers  on  the  person  named  as  guardian  such  powers  as 
would  have  been  exercisable  had  he  been  the  father  and  the  defec- 
tive been  under  the  age  of  fourteen.     The  guardian  also  has  the 


Varieties  of  Establishments  429 

power  of  warning  persons  against  supplying  intoxicants  to  or  for 
the  use  of  the  defective.     [CI.  10  (2).] 

The  term  "  intoxicants  "  includes  any  intoxicating  liquor,  and 
any  sedative,  narcotic,  or  stimulant  drug  or  preparation.     [CI.  71.] 

Varieties  of  Establishments. 

The  varieties  of  establishments  in  which  a  defective  person  may 
be  detained  are  as  follows : 

A.  State  Institutions. — These  are  established,  maintained,  and 
managed  by  the  Board  of  Control  for  defectives  of  criminal,  dan- 
gerous, or  violent  propensities.     [CI.  35.] 

B.  Certified  Institutions  are  those  for  which  a  certificate  has  been 
granted  by  the  Board  upon  being  satisfied  of  their  fitness  for  the 
control  and  care  of  defectives.  Such  institutions  may  be  estab- 
lished and  maintained — 

(i)  By  the  local  authority.     [CI.  38  (i).] 

(2)  By  the  poor-law  guardians  upon  application  of  the  local 
authority.  (They  are  then  called  approved  premises,  but  are  on 
the  same  footing  as  certified  institutions.)     [CI.  37  (i).] 

(3)  By  other  persons.     [CI.  36.] 

C.  Certified  Houses  are  houses  certified  as  fit  by  the  Board  in 
which  defectives  are  received  for  private  profit.  They  may  receive 
and  detain  defectives  under  the  order  of  a  judicial  authority  in  the 
same  way  as  may  certified  institutions;  but  no  part  of  the  cost  of 
maintaining  defectives  in  certified  houses  can  be  paid  out  of  money 
provided  by  Parliament  or  by  the  local  authority.     [CI.  49.] 

D.  Approved  Homes  are  premises  approved  by  the  Board — (i)  in 
which  defectives  are  received  and  supported  wholly  or  partly  by 
voluntary  contributions,  or  by  applying  the  excess  of  payments  of 
some  patients  for  or  towards  the  support  of  other  patients  ;  and 
(2)  houses  in  which  defectives  are  received  for  private  profit. 

It  is  illegal  to  receive  or  detain  in  an  approved  home  any  person 
ordered  to  be  detained  by  a  judicial  authority,  a  court,  or  a  Secre- 
tary of  State.     [CI.  50.] 

Authorities,  their  Powers  and  Duties. 

A.  The  Board  of  Control  is  the  central  authority,  and  consists  of 
fifteen  Commissioners  appointed  by  His  Majesty,  and  a  chairman. 
It  is  charged  with  the  general  superintendence  of  matters  relating 
to  the  supervision,  protection,  and  control  of  defectives  [CI.  21]^ 
including  the  supervision  of  the  administration  by  local  authorities 


430     The  Law   of  England  Concerning  Amentia 

of  their  powers  and  duties  under  the  Act;  the  certification,  inspec- 
tion, and  visitation  of  institutions,  houses,  and  homes;  the  visita- 
tion of  defectives ;  the  provision  and  management  of  State  institu- 
tions.    [CI.  25,  35,  36.] 

B.  The  Local  Authority  is  the  Council  of  the  county  or  county- 
borough  [CI.  27]  acting  through  a  statutory  "  Committee  for  the 
Care  of  the  Mentally  Defective,"  which  may  include  co-opted 
members,  and  to  which  all  matters  relating  to  mental  defectives, 
under  the  Act  (except  that  of  raising  a  rate  or  borrowing  money, 
and  matters  of  urgency)  shall  stand  referred.     [CI.  28.] 

The  duties  of  the  local  authority  are — 

(i)  To  ascertain  what  persons  within  their  area  are  defectives 
subject  to  be  dealt  with  under  the  Act  under  any  of  the  headings 
(i.)  to  (vi.)  enumerated  on  p.  425. 

(2)  To  provide  suitable  supervision  for  such  persons,  or  if  this 
does  not  afford  sufficient  protection,  to  take  steps  for  sending  them 
to  institutions  or  placing  them  under  guardianship. 

(3)  To  provide  suitable  and  sufficient  accommodation  for  such 
persons  as  are  sent  to  certified  institutions  by  orders  under  the 
Act.     [CI.  30.],  etc.,  etc. 

C.  -The  Local  Education  Authority  is  charged  with  the  duty — 

(i)  Of  ascertaining  what  children  within  their  area  are  defective 
children  within  the  meaning  of  this  Act. 

(2)  Of  ascertaining  which  of  such  children  are  incapable  by 
reason  of  mental  defect  of  receiving  benefit  or  further  benefit  from 
instruction  in  special  schools  or  classes.     [CI.  31.] 

{3)  Of  notifying  to  the  local  authority  the  names  and  addresses 
of  defective  children  over  the  age  of  seven — (a)  who  have  been 
ascertained  to  be  incapable  by  reason  of  mental  defect  of  receiving 
benefit  or  further  benefit  in  special  schools  or  classes,  or  who  cannot 
be  instructed  in  a  special  school  or  class  without  detriment  to  the 
interests  of  the  other  children,  or  as  respects  whom  the  Board  of 
Education  certify  that  there  are  special  circumstances  which  render 
it  desirable  that  they  should  be  dealt  with  under  this  Act  by  way 
of  supervision  or  guardianship ;  (&)  who  on  or  before  attaining  the 
age  of  sixteen  are  about  to  be  withdrawn  or  discharged  from  a 
special  school  or  class,  and  in  whose  case  the  local  education 
authority  are  of  opinion  that  it  would  be  to  their  benefit  that  they 
should  be  sent  to  an  institution  or  placed  under  guardianship. 
[CI.  2  (2).] 


Offences,  etc,  43 1 

D.  A  Board  of  Guardians  may,  on  the  application  of  the  local 
authority,  with  the  consent  of  the  Local  Government  Board,  and 
subject  to  the  approval  of  the  Board  of  Control,  enter  into  agree- 
ment with  the  local  authority  to  receive  and  detain  defectives 
(under  orders)  in  buildings  provided  and  managed  by  the  Board  of 
Guardians.     [CI.  37.] 

Offences,  etc. 

It  is  illegal  for  a  person  without  the  consent  of  the  Board  to  under- 
take the  care  and  control  of  more  than  one  defective  person  else- 
where than  in  an  institution,  a  certified  house,  or  an  approved 
home.     [CI.  51  (i).] 

Any  person  undertaking  the  single  care  of  a  defective  as  above 
is  required  within  forty-eight  hours  of  his  reception  to  give  notice 
in  the  prescribed  form  to  the  local  authority  and  to  the  Board. 
[CI.  51  (2).] 

But  this  does  not  apply  to  any  defective  persons  who  may  be 
received  and  detained  in  accordance  with  the  provisions  of  the 
Lunacy  Acts  or  the  Defective  and  Epileptic  Children  Act.  [CI.  51  (4) .] 

It  is  illegal  to  supply  a  defective  with  "  intoxicants  "  after  re- 
ceiving a  warning  not  to  do  so  by  his  guardian.     [CI.  52.] 

It  is  illegal  to  obstruct  a  Commissioner,  Inspector,  Visitor,  or 
authorized  officer  under  the  Act   in  the  exercise  of    his   duties. 

[CI.  54-] 

It  is  illegal  to  carnally  know  or  attempt  so  to  know  any  defec- 
ti\-e  female  under  care  in  an  institution,  certified  house,  or  approved 
home,  or  while  out  on  licence  therefrom,  or  under  guardianship 
under  the  Act;  or  to  procure  or  attempt  to  procure  any  defective 
female  to  have  unlawful  carnal  connection,  whether  within  or 
without  the  King's  dominions,  with  any  person;  or  to  cause  or 
encourage  the  prostitution  of  any  defective  female.     [CI.  56.] 

If  a  patient  escapes  from  an  institution,  he  may  be  apprehended 
without  w^arrant  by  any  constable  or  by  the  managers  of  the  in- 
stitution, or  any  person  authorized  by  them  in  writing,  and  brought 
back  to  the  institution.     [CI.  42.] 

The  maintenance  in  an  institution  or  under  guardianship  of  any 
person  for  whose  maintenance  any  other  person  is  responsible  shall 
not  deprive  that  other  person  of  any  franchise,  right,  or  privilege, 
or  subject  him  to  any  disability.     [CI.  70.] 

The  Idiots  Act,  1886,  is  repealed.     [CI.  67.] 


CHAPTER  XXI 

SOCIOLOGY 

Hitherto  we  have  been  chiefly  concerned  with  aments  as  indi- 
viduals; in  this  final  chapter  it  is  proposed  to  deal  with  them  as 
members  of  the  community,  and  briefly  to  consider  the  subject  of 
mental  defect  from  its  sociological  aspect.  Until  recent  years  no 
reliable  and  at  the  same  time  extensive  statistics  have  existed 
regarding  the  ament  as  a  citizen;  but  the  extremely  valuable  facts 
brought  to  light  by  the  English  Royal  Commission  on  the  Feeble- 
minded of  1904,  together  with  the  Reports  of  "  After-Care  "  Com- 
mittees; of  various  training  institutions;  of  such  bodies  as  that  of 
the  National  Association  for  the  Feeble-minded;  as  well  as  data 
collected  by  independent  inquirers,  now  throw  a  lurid  glare  upon 
the  subject,  and  enable  us  for  the  first  time  to  consider  the  socio- 
logical bearing  of  amentia  in  an  adequate  manner. 

Number. 

The  number  and  distribution  of  mentally  defective  persons  in 
England  and  Wales  has  already  been  mentioned  in  Chapter  II. 
(p.  15),  and  it  was  there  shown  that  on  January  1,  1906,  the  total 
number  of  this  class  was  138,529,  equivalent  to  4-03  per  1,000  of 
the  whole  population,  or  i  defective  person  to  every  248  normal. 
Of  this  total  by  far  the  greatest  proportion  (104,779)  were  of  the 
mildest  or  feeble-minded  grade  of  defect,  the  remainder  being  idiots 
and  imbeciles.  It  may  be  mentioned  that  in  addition  to  these  there 
were  on  the  same  date  approximately  125,827  persons  who  were 
insane  (certified  and  uncertified),  so  that  the  total  number  of  indi- 
viduals suffering  from  pronounced  disease  of  mind  may  be  put 
down  at  264,356,  equivalent  to  i  person  in  every  130  normal,  and 
there  can  be  no  doubt  that  this  rate  is  increasing.  Data  are  not 
available  from  which  we  can  calculate  the  proportion  of  aments 

432 


Employment  433 

with  regard  to  their  social  status,  but  I  think  it  may  be  accepted 
that  there  is  no  very  marked  difference  in  this  respect. 


Employment. 

It  will  generally  be  conceded  that  one  of  the  most  important 
matters  affecting  the  status  of  a  community  is  that  of  the  working 
capacity  of  its  citizens.  If  a  section  exists  which,  by  reason  of 
inefficiency  in  this  respect,  has  to  be  maintained  by  the  remainder 
of  society,  the  economic  value  of  that  society  must  be  impaired. 
If  this  non-productive  section  is  at  all  considerable,  the  burden 
may  be  so  great  as  not  only  to  impede  the  advance  of  the  whole 
community,  but  to  bring  it  to  the  verge  of  bankruptcy.  We  have 
seen  that  the  ratio  of  the  mentally  deficient  is  no  small  one ;  the  first 
question  to  consider,  therefore,  is  that  of  their  productive  utility. 
The  idiots  and  imbeciles  may  be  at  once  eliminated,  for  their 
economic  value  is  practically  nil.  The  feeble-minded,  however, 
who  comprise  by  far  the  greater  proportion,  are  capable  of  useful 
work  under  suitable  supervision — they  have,  indeed,  been  defined 
as  being  able  to  earn  their  living  under  favourable  circumstances — 
so  that  the  question  is:  "To  what  extent  do  the  circumstances  now 
obtaining  admit  of  this  ?" 

Important  information  on  this  point  was  tendered  to  the  Royal 
Commission  by  the  superintendents  of  several  training  establish- 
ments.* Dr.  Caldecott,  the  Medical  Superintendent  of  Earlswood 
Asylum,  sent  out  a  circular  to  the  parents  of  patients  discharged 
during  the  past  fifteen  years,  and  to  this  341  answers  were  received, 
which  showed  that  11  were  at  work  for  wages;  13  at  home,  very 
useful;  26  at  home,  useful;  40  at  home,  no  use.  The  remainder  had 
either  died,  gone  away  with  no  address,  or  had  been  removed  to 
other  institutions.  It  is  to  be  remarked,  however,  that  of  this 
total  number  the  majority  were  idiots  or  imbeciles;  actually  only 
one-fifth  were  of  the  mild  grade  of  defect,  so  that  the  proportion 
of  these  at  work  for  wages  or  very  useful  at  home  may  be  put  down 
as  close  on  30  per  cent. 

At  the  Royal  Albert  Asylum,  Lancaster,  information  was  received 
of  51  patients  who  had  been  discharged  much  improved.  Of 
these,  16  were  earning  wages,  5  were  useful  in  workhouses,  17  were 

*  Report  of  Royal  Commission  on  the   Feeble-minded,    1908,  vol.   viii., 

pp.  158  and  159. 

28 


434  Sociology 

useful  at  home,  6  were  either  not  useful  or  nothing  was  said  of  them, 
4  were  in  lunatic  asylums,  and  3  were  dead.  Dr.  Douglas,  the 
Resident  Medical  Officer,  said:  "  One  thing  I  frequently  observe  is 
that  boys  who  have  learned  a  trade  do  not  continue  it,  but  generally 
turn  to  common  forms  of  labour.  .  .  .  They  need  judicious  super- 
vision, and  an  ordinary  master  or  foreman  will  not  be  troubled  with 
them  while  the  labour  of  perfectly  sane  workmen  can  be  had 
cheaply." 

The  report  of  Mr.  Locke,  from  Starcross  Training  Institute,  is: 
"  I  think  that  during  the  last  ten  years  about  forty  children  have 
been  placed  out  in  the  world.  I  have  information  from  about 
twenty  of  them.  Several  of  these  are  earning  their  own  living 
independently,  but  they  were  brilliant  exceptions.  .  .  ." 

We  may  next  turn  to  the  reports  of  "  After-Care  "  Committees 
regarding  feeble-minded  pupils  of  the  special  schools.  In  London, 
the  proportion  of  pupils  known  to  be  in  "  good  or  promising  " 
employment  was  37-5  per  cent.  Two  years  previously  it  had  been 
45-7  per  cent.,  and  Sir  George  Newman,  the  Chief  Medical  Officer 
to  the  Board  of  Education,*  attributes  the  falling  off  to  two  causes 
— firstly,  insufficient  after-care;  and,  secondly,  the  two  additional 
years.  He  remarks:  "  The  longer  the  test  the  more  severe  it  is.'" 
In  Birmingham,  the  "After-Care"  Committee  compiled  informa- 
tion regarding  932  cases  which  had  passed  through  the  schools 
during  the  previous  ten  years.  Of  these,  excluding  the  normal 
and  dead,  272,  or  34  per  cent.,  were  engaged  in  remunerative  work. 
At  Liverpool,  of  712  children  passing  through  the  hands  of  the 
"  After-Care  "  Committee  during  a  period  of  six  years,  85,  or  11-9. 
per  cent.,  were  doing  remunerative  work. 

Finally,  we  may  refer  to  some  figures  concerning  "  after-care  " 
work  compiled  by  Sir  William  Chance  from  the  returns  of  the 
National  Association  for  the  Feeble-minded, t  These  were  based 
upon  an  inquiry  made  of  sixteen  centres  of  the  Association,  and 
referred  to  a  total  of  3,283  persons.  Of  this  number,  798  were 
doing  remunerative  work,  89  were  "  doing  work,  but  not  reported  " ; 
202  were  useful  at  home;  and  941  were  returned  as  "  useless  mem- 
bers of  society."     If  we  exclude  340  who  were  transferred  to 

*  Report  of  the  Chief  Medical  Of&cer  of  the  Boaxd  of  Education,  191 1 
[Cd.  6530]. 

t  Report  of  Annual  Conference  on  After-Care,  National  Association  for 
the  Feeble-minded.  191 1. 


Pauperism  435 

normal  schools  (not  being  feeble-minded),  we  have  27  per  cent, 
engaged  in  remunerative  work. 

With  regard  to  the  term  "  remunerative  work,"  however,  it  is 
to  be  remarked  that  this  does  not  mean  that  the  person  employed 
is  being  paid  the  standard  wage.  On  the  contrary,  it  is  my  ex- 
perience that  this  is  practically  never  the  case,  and  this  is  cor- 
roborated by  the  observations  of  the  secretary  of  the  Birmingham 
centre,  who  says:  "  Although  some  of  our  cases  have  been  at  work 
for  more  than  ten  years,  only  34  of  the  whole  number  (173) 
earn  as  much  as  los.  2d.  per  week.  Of  these,  only  6  earn  as 
much  as  15s.,  and  only  2  earn  20s.,  which  is  the  highest  wage 
earned.  .  .  .  While  it  is  not  very  difficult  for  some  of  our  higher- 
grade  cases  to  get  work  when  they  first  leave  school,  it  is  almost 
impossible  for  them  to  retain  their  situations  as  they  get  older, 
and  the  difference  between  them  and  their  fellows  becomes  accen- 
tuated. Uncontrolled,  and  often  quite  improperly  cared  for,  they 
rapidly  deteriorate,  the  good  results  obtained  by  the  discipline  and 
training  of  a  special  school  being  under  these  circumstances  dis- 
tinctly evanescent.  .  .  .  There  are  very  few  workers  over  twenty 
years  of  age." 

There  is  no  doubt  that  the  training  which  these  feeble-minded 
children  have  received  (and  all  the  statistics  quoted  above  refer  to 
persons  who  have  had  the  advantage  of  special  training)  varies  very 
considerably.  In  some  instances,  particularly  the  special  institu- 
tions, it  is  excellent;  in  other  instances  it  is  not  so  suitable;  but 
the  failure  seems  to  lie  not  so  much  in  the  methods  of  training  as 
in  the  fact  that  the  mentally  defective  person  is  fundamentallj^ 
incapable  of  managing  himself  and  the  affairs  entrusted  to  him 
without  some  degree  of  supervision,  and  it  is  quite  clear  that  this 
supervision  our  present  social  organization  does  not  supply. 


Pauperism. 

In  view  of  the  preceding  figures,  it  cannot  be  wondered  at  that 
a  very  large  proportion  of  the  feeble-minded  should  sooner  or  later 
go  to  swell  the  ranks  of  the  unemployed,  who  have  to  be  maintained 
by  the  poor  law  authorities,  and  we  may  now  give  some  particulars 
on  this  aspect  of  the  question. 

In  the  eleven  representative  areas  of  England  and  Wales  which 
were  selected  by  the  Royal  Commission  for  personal  investigation. 


43  6  Sociology 

there  were  found  a  total  of  8,813  aments.  The  location  of  these 
has  already  been  shown  in  Table  V.,  p.  18,  and  from  that  it  will 
be  seen  that  no  less  than  40*5  per  cent,  of  the  whole  were  being 
maintained  in  such  institutions  as  workhouses,  training,  rescue, 
and  inebriate  homes  and  penitentiaries,  asylums  and  prisons,  or 
were  receiving  outdoor  parish  relief.  This  total  of  8,813,  however, 
embraces  children  in  public  elementary  schools  as  well  as  idiots 
and  imbeciles,  and  if  we  omit  these  classes,  and  confine  ourselves 
entirely  to  the  adult  feeble-minded,  we  find  no  less  than  67-8  per 
cent,  are  either  inmates  of  institutions  (for  the  most  part  under 
the  poor  law)  or  in  receipt  of  outdoor  relief;  52  per  cent,  of  the 
total  imbeciles  and  54  per  cent,  of  the  total  idiots  are  similarly 
maintained,  partially  or  entirely,  at  the  public  expense ;  and  there  can 
be  no  doubt  that  this  will  happen  in  regard  to  a  very  considerable 
number  of  the  mentally  defective  children  now  in  special  schools. 

The  proportion  of  aments  who,  to  all  intents  and  purposes,  may 
be  looked  upon  as  paupers,  is  thus  seen  to  be  a  large  one;  but 
this  is  only  what  would  be  expected  in  view  of  their  mental  dis- 
abilities, often  combined  with  antisocial  propensities,  which  we 
have  already  described.  It  will  be  of  interest  to  consider  the 
degrees  of  amentia  seriatim. 

Feeble-minded. — With  regard  to  the  adult  feeble-minded,  it  is  a 
striking  fact  that  nearly  two-fifths  of  the  total  number  discovered 
were  found  within  poor-law  institutions.  From  careful  inquiry 
into  the  history  of  those  in  the  Somersetshire  area,  I  found  that 
they  fell  into  the  following  groups,  and  the  same  is  probably  true 
of  the  country  generally : 

{a)  Those  born  in  the  House,  nearly  always  illegitimate. 

(b)  Those  admitted  in  consequence  of  inability  to  earn  their 
living.  Most  of  these  are  below  middle  age ;  they  include  vagrants 
and  street  loafers  brought  in  by  the  police,  and  a  small  section  of 
"  ins-and-outs  "  driven  in  by  stress  of  weather. 

(c)  Those  admitted  in  consequence  of  the  death  of  parents  or 
relations  who  have  hitherto  looked  after  them. 

(d)  Women  admitted  into  the  maternity  wards. 

The  economic  disadvantage  of  such  a  large  proportion  of  these 
persons  being  resident  in  workhouses  is  obvious  when  it  is  stated 
that  the  majority  are  not  in  the  declining  years  of  life,  but  are 
young  adults,  and  that  comparatively  few  of  them  are  remunera- 
tively employed. 


Pauperism  437 

The  inquiries  show  that  more  than  half  are  below  forty-five  years 
of  age,  whilst  from  one-fourth  to  one-third  are  below  thirty.  It 
was  the  general  experience  of  the  investigators  that  more  were 
admitted  between  the  ages  of  twenty  and  thirty  years  than 
during  any  other  decade.  This  tendency  for  the  feeble-minded 
to  drift  into  the  workhouse  quite  early  in  life  is  even  more  pro- 
nounced in  the  large  towns,  and  Dr.  Melland  found  that  in 
Manchester  less  than  one-quarter  of  the  total  number  were  over 
fifty  years  of  age,  "  in  marked  contrast  to  the  normal-minded 
able-bodied  inmates,  the  vast  proportion  of  whom  are  above  that 
age." 

With  regard  to  the  employment  of  these  persons,  Dr.  W.  A. 
Potts,  speaking  of  Birmingham,  says:  "  A  certain  amount  of  em- 
ployment is  found  for  adult  male  defectives,  who  are  taught  boot- 
making,  mat-making,  and  rope-making.  Such  work  might  be 
extended  in  this  and  similar  institutions  with  advantage.  It  is  an 
important  proof  of  what  can  be  done  in  workhouses."  Possibly 
the  same  obtains  in  a  few  other  poor-law  establishments,  but  of 
the  great  majority  throughout  the  country  it  must  be  said  that 
there  is  very  little  attempt  to  employ  these  persons  to  any  economic 
advantage,  and  I  believe  that  the  conditions  which  I  found  to  exist 
in  Somersetshire  are  very  general.  There  I  found  that  about  half 
the  male  feeble-minded  were  more  or  less  (generally  less)  usefully 
engaged  in  coal-carrying,  wood-chopping,  and  the  ordinary  domestic 
work  of  the  institution,  whilst  about  two-thirds  of  the  females  were 
doing  a  little  scrubbing,  mending,  and  laundry  work.  The  re- 
mainder were  idle,  and  simply  loafed  about,  many  of  them  being 
either  incorrigibly  lazy  or  requiring  so  much  supervision  that  they 
were  more  bother  than  they  were  worth. 

In  fact,  the  presence  of  such  a  large  proportion  of  feeble-minded 
persons  in  workhouses  is  not  due  to  any  definite  administrative 
attempt  to  provide  for  this  class,  or  even  to  the  suitability  of  these 
institutions.  It  is  solely  and  simply  a  result  of  the  inevitable  ten- 
dency for  the  non- supervised  ament  to  drift  out  of  life's  stream 
into  the  nearest  backwater.  I  calculate  that  about  18  per  cent, 
of  the  workhouse  inmates  of  this  country  are  feeble-minded.  It 
will  be  obvious  that  the  cost  to  the  State  of  these  persons  must  be 
very  considerable.  A  short  time  ago  a  feeble-minded  woman  died 
in  a  workhouse  in  Sussex  at  the  age  of  eighty-nine  years.  She  had 
been  under  the  care  of  the  Guardians  since  she  was  four  days  old, 


43  8  Sociology 

and  the  Clerk  to  the  Board  stated  that  she  had  cost  the  ratepayers 
roughly  ;^i,6oo. 

Similarly  with  regard  to  those  in  receipt  of  outdoor  relief:  most 
of  them  are  young  adults,  and  although  a  percentage  are  doing 
work  which  contributes  to  their  support,  there  is  no  doubt  that 
under  a  proper  system  they  might  be  employed  to  much  greater 
advantage.  Less  than  one-fourth  of  those  in  Manchester  were  use- 
fully employed;  in  the  country  districts,  however,  where  work  of  a 
character  more  suited  to  the  capacity  of  these  persons  is  available, 
from  one-half  to  two-thirds  manage  to  earn  a  little.  The  weekly 
allowance  which  these  defectives  receive  from  the  parish  varies 
very  greatly  in  the  different  unions;  on  the  average  it  is  probably 
about  two  shillings  or  half  a  crown,  and  with  this  and  the  shilling 
or  so  they  earn,  supplemented  by  an  occasional  gift  of  boots  or 
cast-off  clothes,  they  manage  to  exist  tolerably  well  as  long  as 
they  have  someone  to  provide  them  with  shelter,  and  generally 
take  care  of  them.  When  their  protectors  die,  the  refuge  of  all 
these  persons  will  be  the  workhouse. 

The  fact  that  lo  per  cent,  of  feeble-minded  persons  are  resident 
in  lunatic  asylums  is  an  indication  of  the  mental  instability,  as 
well  as  deficiency,  of  this  class.  For  the  incarceration  of  practi- 
cally all  of  them  is  due  to  insanity  or  epilepsy. 

It  is  apparent  from  these  inquiries,  that  not  only  do  a  larger  pro- 
portion of  town  than  country  defectives  receive  poor-law  relief, 
but  that  both  absolutely  and  relatively  far  more  are  relieved  in 
the  House.  It  is  to  be  remembered  that  these  remarks  relate  to 
the  feeble-minded  degree  of  defect  only,  a  class  which  is  defined 
as  being  "  capable  of  earning  a  living  under  favourable  circum- 
stances," The  facts  are  sufficient  evidence  as  to  how  little  favour- 
able the  actual  circumstances  at  present  are,  and  it  may  be  re- 
marked that  not  a  few  of  these  feeble-minded  paupers  have  been 
educated  at  great  cost  in  special  schools.  How  illogical  is  the 
system  which  spends  thousands  upon  the  training  of  mentally 
defective  children,  and  then  turns  them  adrift  to  shift  for  them- 
selves as  best  they  can  ! 

I  have  already  remarked  that  competition  is  much  more  adverse 
to  the  feeble-minded  in  the  towns  than  in  the  country,  and  that 
in  consequence  a  larger  proportion  of  them  gravitate  into  institu- 
tions. This  is  well  shown  by  the  following  table,  which  I  have 
compiled  from  the  Royal  Commission  Reports: 


Pauperism 


439 


TABLE  XVI. 

Showing  the  Location  of  Feeble-minded  in  Urban  and  Rural 
Areas  Respectively. 


In 

Institutions 
(Paupers) . 

In  Receipt  of 
Outdoor 
Relief. 

Not  at  Present  receiving 
Relief. 

Relief  will 

probably  be 

required 

upon  J^eath  of 

Friends. 

Friends  capable 

of  making 
Permanent  Pro- 
vision.* 

Urban  and  industrial 

areas 

Rural  areas . . 

Per  Cent. 
76-2 

Per  Cent. 
2-7 

Per  Cent. 
19-2 

39-8 

Per  Cent. 

1-7 

13-6 

79-0 

25-7                          20-7 

46-4 

Idiots  and  Imbeciles. — Of  the  idiots  and  imbeciles  about  54  per 
cent,  are  paupers,  of  whom  about  two-thirds  are  in  institutions, 
and  one-third  in  receipt  of  outdoor  relief.  Of  those  in  institutions, 
nearly  two-thirds  are  in  idiot  or  lunatic  asylums,  and  the  remainder 
in  workhouses.  There  is  no  doubt,  however,  that  a  considerable 
number  of  the  imbeciles  at  present  attending  elementary  schools 
(where  they  learn  nothing,  and  are  often  a  considerable  annoyance 
and  distraction  to  teachers  and  scholars  alike)  will  eventually 
become  a  charge  upon  the  rates,  whilst  a  large  proportion  of  those 
not  at  present  in  receipt  of  relief  will  need  provision  upon  the  death 
of  their  parents. 

With  regard  to  the  granting  of  relief  to  idiots  and  imbeciles,  it  is- 
interesting  to  notice  the  difference  of  method  between  town  and 
country  districts  respectively.  The  proportion  actually  relieved  in 
the  two  situations  is  pretty  much  the  same;  but  whereas  in  the 
towns  36  per  cent,  are  in  the  workhouse  and  7  per  cent,  outside, 
in  the  country  there  are  but  14  per  cent,  in  the  [House,  as  against 
32  per^cent.  receiving  outdoor  relief. 

*  Owing  to  difficulty  of  investigation,  this  class  is  probably  understated. 


44°  Sociology- 

Vagrancy. 

We  may  now  consider  the  question  of  vagrancy.  Many  feeble- 
minded persons,  with  a  home  to  which  they  can  turn,  have  such 
a  propensity  for  wandering  that  they  will  roam  the  country  for 
miles  round,  and  sometimes  be  away  for  days  together.  These  are 
often  well  known  to  all  the  country-side,  and  they  frequently  get 
a  plate  of  food  and  a  shakedown  in  the  barn  of  some  hospitable 
farmer;  failing  that,  they  spend  the  night  in  a  dry  ditch.  I  do 
not  think  they  usually  have  any  definite  objective;  they  simply 
ramble  on  where  the  fit  takes  them.  I  remember  once  pursuing 
one  of  these  youths,  whom  I  particularly  wanted  to  find,  for  a 
whole  day.  I  got  scent  of  him  from  time  to  time,  but,  although  I 
was  driving  and  he  was  on  foot,  it  was  nightfall  before  I  overtook 
him,  and  he  must  have  walked  at  least  twenty  miles.  Neyroz  * 
describes  the  case  of  one  of  these  persons,  confined  in  an  Italian 
asylum,  who  repeatedly  escaped  in  order  to  visit  neighbouring 
cities  and  write  an  account  of  his  experiences  on  his  return.  His 
wanderings  were  very  extensive,  and  his  written  accounts  very 
circumstantial;  but  investigations  showed  that,  although  he  had 
undoubtedly  been  to  the  places  he  described,  his  descriptions  were 
largely  imaginative.  In  this  case  the  route  was  carefully  marked 
out  beforehand  by  means  of  atlases  and  geography  books,  but  his 
limited  mental  capacity  prevented  him  making  any  real  use  of  the 
itinerary  he  had  compiled. 

On  the  other  hand,  a  small  number  have  no  permanent  home, 
but  simply  shift  for  themselves  as  best  they  may,  and  these,  per- 
haps, are  more  properly  called  vagrants.  As  a  rule  they  are  the 
least  defective  members  of  the  feeble-minded,  and  although  the 
bulk  of  them  drift  into  the  workhouse  sooner  or  later,  they  do  for 
a  time,  particularly  in  the  country,  manage  to  exist  by  their  wits. 
How  this  is  accomplished  can  generally  only  be  conjectured;  many 
of  them  seem  to  be  itinerant  vendors  of  something  or  other,  and  no 
doubt  they  often  get  a  free  meal  or  cast-off  suit  of  clothes  given  to 
them,  failing  which  they  are  not  averse  to  begging.  Some  years 
ago  I  used  constantly  to  meet  a  feeble-minded  couple  of  this  de- 
scription— man  and  wife — who  roamed  the  country  collecting  rags, 
bones,  rabbit-skins,  and  suchlike.  But  my  inquiries  showed  that 
their  defect  gave  them  an  unfair  advantage  over  their  normal- 

*  N.  Neyroz,  abstract  in  Journal  of  Mental  Science,  July,  1905,  p.  618, 


Aments  under  Inadequate  Care  44^ 

witted  competitors,  inasmuch  as  compassion  gained  for  them  what 
money  had  to  procure  for  the  others,  and  this  is  probably  the  case 
with  most  of  the  feeble-minded  living  bv  their  wits.  A  few  of 
these  persons  manage  to  earn  enough  to  pay  for  bed  and  breakfast 
in  a  common  lodging-house;  these,  however,  are  the  elite,  and  the 
majority  either  sleep  "  rough  "  or  get  a  bed  in  the  casual  ward. 
The  inquiries  of  the  Royal  Commission  show  that  on  the  whole 
about  10  per  cent,  of  the  feeble-minded  come  within  the  category 
of  vagrants,  whilst  about  lo  per  cent,  of  all  vagrants  are  feeble- 
minded. For  the  most  part  I  think  they  are  well-behaved  and 
inoffensive,  but  some  have  decided  insane  or  criminal  tendencies, 
and  such  are  an  undoubted  menace  to  society. 

Aments  under  Inadequate  Care. 

By  no  means  one  of  the  least  important  of  the  facts  ascertained 
by  the  Royal  Commission  was  that  of  the  number  of  aments,  in 
the  eleven  areas  examined,  whose  care  and  control  was  inadequate, 
and  for  whom  further  provision  is  needed,  either  (i)  in  the  interests 
of  the  patients  themselves,  or  (2)  for  the  pubhc  safety.  The  former 
group  consists  of  persons  who,  in  the  opinion  of  the  respective 
investigators,  are  unsuitably  or  unkindly  cared  for;  the  latter,  of 
aments  possessing  habits  and  propensities  which  render  them  a 
source  of  danger  to  the  community  in  which  they  live.  It  was 
recognized  that  many  persons  might  be  living  under  conditions 
which  were  not  ideal,  but  these  were  not  included,  the  object  being 
to  ascertain  the  irreducible  minimum  in  urgent  need  of  provision 
at  the  present  time.  I  propose  to  quote  these  figures  as  affording 
statistical  proof  of  the  extremely  unsatisfactory  relationship  at 
present  existing  between  the  ament  and  society. 

In  column  2  of  the  following  table  is  shown  the  percentage  of 
persons  suffering  from  each  of  the  three  degrees  of  defect  who  were 
found  to  be  inadequately  cared  for  in  the  areas  examined.  There 
is  no  reason  for  thinking  that  these  results  are  other  than  typical 
of  the  entire  country;  column  3  therefore  shows  the  estimated  total 
number  of  these  persons  in  England  and  Wales:* 

*  This  estimate  does  not  include  feeble-minded  ("  mentally  deficient  ") 
children,  who,  according  to  the  Report  of  the  Royal  Commission,  number 
35,662,  or  0'59  per  cent,  of  the  children  on  the  school  register;  nor  does  it 
include  sane  epileptics.  If  these  two  classes  are  included,  the  total  number 
of  persons  urgently  in  need  of  provision,  according  to  the  Report  of  the  Royal 
Commission,  is  66,509. 


442 


Sociology 


TABLE  XVII. 

Aments  Inadequately  Cared  for. 


Degree  of  Defect. 

Percentage  inadequately 

cared  for  to  Total 

Number  in  Eleven 

Areas  investigated  by 

Royal  Commission. 

Estimated  Total 
Number  inadequately 

cared  for  in 
England  and  Wales. 

Idiots  . . 

Imbeciles 

Feeble-minded  persons 

40- 8  per  cent, 
46*2         ,, 
31-8         .. 

2,381 

7,689 

15.793 

It  will  be  of  interest  to  note  the  chief  locations  of  these  persons 
needing  further  provision.  In  the  case  of  the  feeble-minded,  the 
highest  proportion  of  those  unsatisfactorily  provided  for  occurs  in 
the  classes  at  large  and  in  charitable  institutions,  in  which  situa- 
tions between  40  and  50  per  cent,  require  further  care.  With 
regard  to  those  at  large  this  high  proportion  is  not  surprising,  but 
a  word  of  explanation  is  necessary  in  reference  to  the  charitable 
homes.  The  high  proportion  here  is  not  any  reflection  upon  these 
homes,  but  is  simply  due  to  the  fact  that  their  provision  is  tem- 
porary and  optional  only,  and  that  most  of  the  inmates  are  feeble- 
minded girls  who  have  given  birth  to  children.  It  is  obvious  that 
in  the  case  of  such  persons  detention  should  be  permanent  and 
compulsory.  About  one-fifth  of  the  feeble-minded  in  workhouses, 
and  one-fourth  of  those  in  receipt  of  outdoor  relief,  are  reported  to 
be  unsatisfactorily  provided  for. 

Of  the  idiots  and  imbeciles,  the  greatest  proportion  in  need  of 
provision  occurs  amongst  those  receiving  outdoor  relief.  In  two- 
thirds  of  these  the  present  conditions  are  so  unsatisfactory  as  to 
urgently  call  for  amendment,  and  nearly  all  of  these  are  in  rural 
districts.  Of  those  at  large  in  fairly  well-to-do  circumstances,  one- 
quarter  require  further  care  or  control ;  whilst  of  those  at  large  who 
are  the  offspring  of  the  labouring  class,  the  present  provision  is 
unsatisfactory  in  one-half.  There  can  be  no  doubt  that  the  presence 
of  these  persons  in  small  and  often  overcrowded  cottages  is  fraught 
with  considerable  possibilities  of  harm.  But  even  apart  from 
actual  danger,  want  of  time  and  want  of  knowledge  on  the  part  of 
the  parents  must  prevent  the  imbecile  or  idiot  receiving  the  atten- 


Crime  443 

tion  he  needs,  and  which  he  would  obtain  in  an  institution;  whilst 
his  presence  cannot  be  regarded  as  conducive  to  the  comfort  of  the 
home.  As  far  as  the  idiots  and  imbeciles  themselves  are  concerned, 
the  accommodation  provided  by  the  workhouses  is  tolerably  satis- 
factory; it  is  rarely,  however,  that  any  special  wards  exist  for  them, 
and  it  must  be  admitted  that  the  other  inmates  often  view  the 
question  in  a  somewhat  different  light.  Indeed,  from  remarks 
which  have  been  frequently  made  to  me,  I  am  disposed  to  think 
that  no  little  of  the  reluctance  evinced  by  the  poor  classes  to  avail 
themselves  of  the  House,  and  even  of  the  workhouse  infirmary,  is 
due  to  the  presence  therein  of  the  mentally  defective. 

Crime. 

The  question  of  mental  defect  and  crime  was  considered  in 
Chapter  XV.,  and  it  was  there  shown  that  approximately  10  per 
•cent,  of  aments  evinced  a  marked  propensity  towards  the  commis- 
sion of  criminal  offences,  equivalent  to  a  total  of  about  13,000  such 
persons  in  England  and  Wales.  Conversely,  about  20  per  cent,  of 
the  total  number  of  prisoners  are  mentally  deficient. 

It  is  important  to  realize  that  the  lapses  of  these  persons  are  not 
isolated  events  in  their  life-history.  On  the  contrary,  the  average 
number  of  convictions  per  person  is  considerable,  and  I  have  met 
with  many  aments  who  have  served  scores,  some  even  hundreds, 
of  sentences.  In  giving  evidence  on  this  point  before  the  Royal 
Commission,  Dr.  Smalley  said:  "  Against  130  out  of  333  weak- 
minded  prisoners  who  were  unfit  for  ordinary  penal  discipline  by 
reason  of  mental  deficiency,  no  previous  conviction  had  been  re- 
corded; but  for  this  absence  of  record  their  nomadic  habits  might 
in  part  account.  Against  fifty-six  i  conviction  had  been  re- 
corded, against  twenty-eight  2;  the  remainder  varied  from  4  to 
105  convictions.  About  half  had  been  convicted  from  5  to 
10  times.  .  .  .  The  bulk  of  them  become  habitual  criminals. 
Their  tendency  to  recidivism  is  strongly  marked,  and  it  would 
seem,  from  a  consideration  of  individual  cases,  to  be  almost  an 
invariable  rule  for  persons  of  this  type  who  have  once  manifested 
•criminal  inclinations  to  become  prison  habitues,  and  to  steadily 
deteriorate  morally  and  intellectually  under  the  present  regime." 
Dr.  Hamblin  Smith,*  Medical  Officer  of  Stafford  Prison,   as  the 

*  M.  Hamblin  Smith,  "  Notes  on  loo  Mentally  Defective  Prisoners," 
Journal  of  Menial  Science,  April,  1913,  p.  326. 


444  Sociology 

result  of  a  special  inquiry  into  lOO  mentally  defective  prisoners, 
found  that  the  lOO  had  a  combined  record  of  1,104  convictions,  or 
an  average  of  11  per  prisoner,  and  this  number  was  regarded 
as  being  below  the  actual  truth.  Ten  of  the  prisoners  had  over 
30  previous  convictions.  Dr.  W.  R.  Dawson*  found  that  in  the 
two  prisons  in  Dublin  12  "21  per  cent,  of  the  inmates  were  defec- 
tives. The  average  number  of  previous  convictions  for  the  male 
defectives  was  1776,  and  fifteen  of  them  had  over  50  convictions 
each.  The  average  number  of  previous  convictions  for  the  females 
was  44"i3.  Many  of  them  ran  into  hundreds,  and  one  was  in  prison 
for  the  two  hundred  and  thirty-sixth  time,  and  she  was  only  twenty- 
nine  years  old.  There  is,  indeed,  no  occasion  to  labour  this  point 
any  further,  for  it  is  the  experience  of  all  who  have  had  any  prac- 
tical dealings  with  this  class  that,  as  Dr.  Smalley  said,  "  the  ten- 
dency to  recidivism  is  strongly  marked." 

In  most  instances  the  offences  committed  by  these  persons  are 
of  a  minor  character;  at  the  same  time,  the  number  of  serious 
offences  amounts  to  no  inconsiderable  total.  Their  nature,  in 
order  of  frequency,  is  as  follows:  Drunkenness,  vagrancy,  begging, 
larceny  and  housebreaking,  prostitution,  neglect  of  children,  in- 
decent assaults,  common  assaults,  arson,  suicide,  and  homicide. 
The  returns  of  in  weak-minded  convicts  at  Parkhurst  reveal, 
amongst  others,  13  instances  of  attempting  to  murder,  10  of  carnal 
knowledge  of  girls  under  thirteen  years  of  age,  9  of  murder,  5  of 
manslaughter,  and  3  of  rape. 

Inebriety. 

We  may  now  briefly  refer  to  the  question  of  inebriety.  The 
relationship  existing  between  alcoholism  and  mental  defect  is  of 
two  kinds.  As  pointed  out  in  dealing  with  causation,  I  hold  the 
view  that  excessive  and  long-continued  indulgence  in  alcohol  may 
so  impair  the  germ  plasm  as  to  produce  mental  defect  in  the  offspring. 
On  the  other  hand,  there  is  no  doubt  that  the  "  craving  for  drink  " 
is  very  often  only  a  symptom  of  some  degree  of  mental  impairment 
already  present.  Its  effects,  moreover,  are  much  more  potent  in 
the  case  of  the  neuropathic  and  psychopathic  than  in  that  of  the 
normal  population.  Since  the  passing  of  the  Inebriates  Act  of 
1898,  and  the  consequent  temporary  detention  of  a  certain  propor- 
tion of  chronic  inebriates  in  reformatories,  it  has  become  possible 
*  W.  R.  Dawson,  Journal  of  Mental  Science,  July,  1910,  p.  466. 


Inebriety  445 

to  ascertain  certain  data  regarding  this  class  which  were  previously 
unobtainable,  and  these  are  so  striking  as  to  be  worth  quoting. 

A  return*  of  1,873  persons  admitted  to  reformatories,  where 
they  are  kept  under  conditions  which  afford  perfect  opportunity 
for  close  observation,  shows  that  48  were  insane,  and  subsequently 
certified  and  sent  to  asylums;  271  were  very  defective  (imbeciles, 
degenerates,  epileptics) ;  857  were  defective  in  less  degree  (eccentric, 
silly,  dull,  senile,  or  subject  to  periodical  paroxysms  of  ungovern- 
able temper) ;  and  697  were  of  average  mental  capacity  (on  admis- 
sion or  after  six  months'  detention).  In  the  category  of  defective 
and  very  defective  there  are,  therefore,  1,128  persons,  or  60  per 
cent,  of  the  whole;  and  "  nearly  all  these  gave  evidence  of  pos- 
sessing some  of  the  peculiarities  in  cranial  conformation,  general 
physique,  and  conduct,  which  have  long  been  recognized  as  evidence 
of  congenital  defect." 

Dr.  Branthwaite,  Inspector  under  the  Inebriates  Acts,  says  that 
two-thirds  of  the  persons  committed  to  reformatories  were  irre- 
formable,  and  that  the  main  factor  determining  their  irreformability 
was  their  mental  condition.  "  Very  many  of  the  cases  sent  to  us 
from  the  courts  under  this  Act  are  none  other  than  just  feeble- 
minded persons,  drunkards  simply  because  they  are  feeble-minded. 
.  .  .  The  removal  of  liquor  from  some  of  these  persons,  even  for 
long  periods,  does  not  greatly  improve  their  mental  state,  and  this 
is  especially  so  in  the  congenitally  defective  who  are  the  progeny 
of  feeble-minded,  lunatic,  epileptic,  or  drunken  parents." 

The  Superintendent  of  Brentry  Reformatory  says  that  of  70  per 
cent,  of  cases  he  "  cannot  conceive  the  possibility  of  their  ever 
acquiring  sufficient  self-control  to  be  able  to  keep  them  from 
drunkenness  and  support  themselves."  Dr.  Gill,  of  the  Langho 
Reformatory,  estimates  that  50  per  cent,  of  inmates  are  mentally 
defective.  Dr.  Winder,  of  the  State  Inebriate  Reformatory  at 
Aylesbury,  says  that  out  of  167  patients  received  since  1901, 
"  25  per  cent,  are  definitely  and  undoubtedly  feeble-minded  high- 
grade  imbeciles.  ...  If,  however,  the  term  '  feeble-minded  '  is 
to  be  extended  over  a  broader  basis,  and  made  to  include  all  those 
individuals  who  are  abnormally  excitable,  subject  to  attacks  of 
uncontrollable  temper,  perverted  morally,  inconsequent  in  ideas,  of 

*  Report  of  the  Royal  Commission  on  the  Feeble-minded,  1908,  vol.  viii., 
p.  137.  See  also  the  Report  of  Dr.  Branthwaite,  Inspector  under  the  In- 
ebriates Acts,  igog,  Cd.  579g. 


44^  Sociology 

feeble  reasoning  powers,  and  unable  to  acquire  knowledge  beyond 
the  most  rudimentary  principles,  then  nearly  all  might  be  classed 
as  feeble-minded,  but  certainly  over  70  per  cent,  should  be  so 
defined.  They  are  so  mentally  unstable  as  to  be  incapable  of 
earning  their  livelihood  on  equal  terms  with  their  normal  fellows." 


Propagation. 

The  next  sociological  consideration  to  which  I  desire  to  draw 
attention  is  that  of  the  rate  of  propagation  of  aments.  I  think  it 
has  long  been  recognized  by  psychiatrists  that  the  birth-rate  in 
psychopathic  families  tends  to  be  high,  but  it  is  only  since  the 
birth-rate  of  the  general  community  has  fallen  (that  of  the  mentally 
abnormal  remaining  at  its  previous  high  level)  that  the  matter  has 
assumed  a  serious  aspect,  and  has  begun  to  attract  attention. 
Some  inquiries  which  I  made  on  this  subject  in  1900  showed  that, 
whilst  the  average  number  of  births  to  a  marriage  in  England  and 
Wales  was  4"63,  the  average  number  in  markedly  psychopathic 
families  was  7*3.  At  the  time,  these  figures  were  either  unnoticed 
or  received  with  some  scepticism ;  but  their  accuracy  has  since  been 
amply  demonstrated  by  other  independent  inquiries,  and  there 
can  be  no  doubt  that  the  disproportion  obtaining  between  the 
birth-rate  of  the  "  fit  "  and  the  "  unfit  "  has  now  become  a  problem 
of  most  serious  significance  to  the  nation. 

Dr.  Ettie  Sayer*  made  an  inquiry  into  this  and  other  points 
regarding  mentalty  defective  children  attending  the  special  schools 
in  London.  The  inquiry  lasted  two  years  (1904-1906),  and  in  order 
to  avoid  selection  the  name  of  every  seventh  child  in  the  school 
registers  was  taken,  and  the  family  history  followed  up,  the  same 
process  being  adopted  in  a  normal  school.  It  was  found  that  in 
100  normal  families  there  was  a  total  of  506  children  and  23  mis- 
carriages, 387  of  the  children  being  still  alive.  On  the  other  hand, 
in  the  families  from  which  the  100  mentally  defective  children  came 
there  was  a  total  of  761  children  born,  loi  miscarriages,  and  467 
children  living. 

Miss  Mary  Dendy,  the  founder  of  the  Sandlebridge  Colony, 
Cheshire,  a  lady  whose  interest  in,  and  knowledge  of,  the  mentally 
deficient  are  well  known  throughout  the  country,  tells  me  that  she 
has  investigated  the  family  history  of  a  large  number  of  these 

*  Ettie  Sayer,  Eugenics  Review,  July,  1913,  p.  162. 


Propagation  447 

persons,  and  has  no  doubt  whatever  that  the  birth-rate  amongst 
them  is  considerably  higher  than  among  the  normal  population. 

Similar  results  are  forthcoming  from  America.*  Dr.  Johnstone 
found  that  feeble-minded  women  were  nearly  twice  as  prolific  as 
normal  females;  whilst  Dr.  Kiernan's  investigations  of  ninety  de- 
generate families  disclosed  the  average  number  of  children  to  be 
eleven ;  also  that  multiple  births  occurred  ten  times  more  frequently 
than  in  the  general  population. 

The  evidence  is  clear,  then,  that  the  birth-rate  in  psychopathic 
families  is  now  very  considerably  in  excess  of  that  in  the  non- 
psychopathic.  The  question  naturally  arises:  "What  is  the  con- 
dition of  the  offspring  as  a  whole  ?  Are  they  on  the  average  up  to 
the  normal  standard,  or  do  they  show  some  social  inferiority  ?" 
As  throwing  some  light  on  this  subject,  I  may  refer  to  some  par- 
ticulars ascertained  during  the  course  of  my  investigations  in 
Somersetshire.  Of  61  feeble-minded  women  whom  I  found  had 
given  birth  to  children,  19  were  married  and  42  unmarried.  The 
19  married  have  hitherto  produced  a  total  of  80  children.  Of  these, 
16  died  in  infancy,  19  are  imbecile  or  feeble-minded,  20  are  either 
physically  delicate  to  a  pronounced  degree  or  are  mentally  dull  and 
backward,  whilst  8  are  too  young  to  satisfactorily  examine.  There 
are  only  17  out  of  the  total  80  who  appear  to  come  up  to  the  average 
standard  of  mental  and  bodily  health.  With  regard  to  the  illegiti- 
mate children,  the  particulars  are  of  necessity  less  complete.  The 
42  mothers  have  so  far  produced  78  children.  Of  these,  24  died  in 
infancy,  5  are  imbecile  or  feeble-minded,  2  are  markedly  dull  and 
backward,  2  appear  to  be  normal,  and  the  remaining  45  have  been 
completely  lost  sight  of.  It  must  be  remembered  that  in  practi- 
cally all  these  cases  information  as  to  the  paternal  inheritance  of 
these  children  is  unobtainable. 

To  these  particulars  I  may  add  some  details  regarding  the  brothers 
and  sisters  of  150  aments  whose  family  history  I  investigated  in 
1900.  I  divided  these  into  two  classes,  which  were  designated 
"  satisfactory "  and  "  unsatisfactory."  The  satisfactory  group 
comprised  all  those  who  were  said  to  be  healthy  in  mind  and  body, 
and  were  able  to  support  themselves.  The  unsatisfactory  consisted, 
in  addition  to  those  prematurely  dead,  of  those  who  were  either 
mentally  affected,  or  were  suffering  from  marked  and  permanent 
ill-health,  or  were  leading  a  life  of  vagabondage  or  crime.     Such 

*  Quoted  by  Dr.  H.  Work,  Americayi  Journal  of  Insanity,  July,  igi2. 


448 


Sociology 


details  were,  of  course,  difficult  to  get,  and  as  the  valuation  was 
generally  that  of  the  parents,  the  figures  are  almost  certainly  more 
favourable  to  the  class  than  is  really  the  case.  These  figures  are 
shown  in  the  following  table : 


TABLE  XVIII. 

Showing  the  Condition  of  150  Aments  with  their  Brothers  and 

Sisters. 

{In  the  1^0  families  there  were  1,269  children  born.) 


Unsatisfactory. 

Satisfactory. 

(a)  Born  dead 

(b)  Since  died: 

Under  i  year  .  . 

,,       3  years. . 

„      10      ,,     .  . 

,,     20 
Over  20      „ 

(c)  Mentally  affected 

{d)  Diseased,    paupers, 
criminals 

107 

37 
8 

or 

170 

-315 

245 
83 

Said     by     parents    to     be 
mentally       and        bodily 
healthy      . .          . .          . .      456 

Total 

..      813 

Total           . .          . .      456 

1,269 

Some  points  in  this  table  are  worthy  of  note.  Firstly,  the  large 
number  of  children  born.  According  to  the  Fortieth  Annual 
Report  of  the  Registrar-General,  the  average  number  of  births  to 
a  marriage  in  England  and  Wales  in  1876  was  4-63.  The  number 
of  children  in  150  normal  families  would  therefore  be  694;  whereas 
in  the  families  we  are  now  considering  the  number  born  alive  is 
1,099,  or  3-^  average  of  7-3  per  family.  Secondly,  the  large  number 
of  stillbirths.  No  precise  data  exist  with  regard  to  the  number  of 
these  in  the  normal  population,  as  they  are  unregistered,  but  Farr 
and  Newsholme  estimate  them  at  about  4  per  cent,  of  the  total 
births.  If  these  families  were  normal,  we  should  therefore  expect 
to  have  44  children  stillborn,  whereas  we  find  170.  Thirdly,  the 
mortality  of  these  children  is  even  more  remarkable.     According 


Propagation  449 

to  the  life-table  of  the  Registrar-General,  based  upon  the  years 
1881-1890  (Supplement  to  Fifty-Fifth  Annual  Report,  1895) — 

Had  the  1,099  Children  belonged  to  the  "  Average  "  Whereas  there  were 

Class,  there  would  have  been  surviving —  surviving — 

At  end  of  i  year  . .  937  .  .  . .  . .  961 

>>       M     3  years  . .  864  . .  . .  . .  854 

„       „    10       „  ,.  823  ..  ..  ..  817 

,,       ,,    20       ,,  . .  800  . .  . .  , .  809 

In  other  words,  the  mortality  is  practically  identical  with  the 
normal. 

I  do  not  \vish  to  press  the  point  unduly,  because  the  number 
dealt  with  is  but  small;  but  I  think,  in  view  of  the  steady  dechne 
in  the  birth-rate  of  the  general  population  which  has  taken  place 
since  1878,  there  can  be  no  doubt  that  the  offspring  of  the  psycho- 
pathic are  not  merely  holding  their  own  in  proportion  to  the  entire 
population,  but  are  undergoing  a  steady  increase.  And,  even 
assuming  that  the  456  brothers  and  sisters  of  these  aments  are 
really  sound  in  body  and  mind,  as  stated  by  their  parents  (which, 
however,  I  greatly  doubt),  it  is  to  be  remembered  that  they  come 
of  a  pronounced  morbid  stock,  and  are  not  only  capable  of,  but 
■exceedingly  likely  to  transmit  the  taint  to  a  subsequent  generation. 

It  is  to  be  remarked  that  these  are  families  in  which  as  a  rule  the 
psychopathic  condition  is  evident  in  one  of  the  parents  only.  I 
have  obtained  particulars  of  many  families  in  which  both  parents 
have  borne  the  taint,  and  in  such  cases  I  have  never  yet  seen 
normal  offspring. 

On  this  point  we  may  refer  to  some  valuable  researches  which 
have  recently  been  made  in  America  under  the  auspices  of  the 
Eugenics  Record  Office.  The  history  of  the  "  Hill  Folk  "*  well 
illustrates  how  the  social  status  of  a  whole  district  may  be  deter- 
mined by  the  multiplication  of  an  undesirable  stock.  In  the  neigh- 
bourhood of  a  small  town  lying  among  the  New  England  hills  there 
is  a  population  among  which  feeble-mindedness,  alcoholism,  and 
immorality  are  rife.  It  was  found  that  practically  all  the  less 
desirable  inhabitants  could  be  traced  back  to  one  of  two  original 
sources — a  shiftless  basket-maker,  probably  of  French  origin,  and 
an  Enghshman,  both  of  whom  migrated  into  the  district  about  the 
year  1800.     Their  descendants  comprise  the  "  Hill  Folk  "  described 

*  Florence  H.  Danielson  and  Charles  B.  Davenport,  "  The  Hill  Folk," 
Bulletin  of  Eugenics  Record  Office,  August,  191 2. 

29 


450  Sociology 

in  this  memoir,  and  it  was  found  that  between  1879  and  1889  they 
absorbed  almost  one-tenth  of  the  whole  amount  spent  by  this 
town  in  poor-law  relief.  This  proportion  has  now  risen  to  more 
than  one-fourth,  and  during  the  past  thirty  years  sixteen  of  these 
descendants  have  been  sentenced  for  serious  offences,  mostly  of  a 
sexual  character,  their  punishment  costing  the  State  about  10,000 
dollars.  The  pedigree  charts  which  accompany  this  interesting 
record  show  the  extensive  prevalence  of  feeble-mindedness  among 
this  stock. 

Another  genealogical  study  made  under  the  samxC  auspices 
relates  to  the  descendants  of  Joseph  "  Xam,"*  who  lived  in  the 
mountains  of  Massachusetts  about  1760.  The  original  Nam  had 
eight  children,  some  of  the  descendants  of  whom  were  prosperous, 
but  the  majority  sank  into  the  lowest  social  grade,  and  are  now- 
living  under  the  most  ^^Tetched  conditions.  Of  784  descendants 
who  have  been  traced,  it  was  found  that  88  per  cent,  of  females 
and  90  per  cent,  of  males  were  excessively  addicted  to  alcohol; 
180  were  illegitimate;  there  were  232  licentious  women  and  199 
Hcentious  men,  as  contrasted  wath  155  chaste  women  and  83  chaste 
men;  there  were  19  epileptics,  24  insane,  of  whom  7  have  been  in 
custodial  care,  3  in  a  girls'  home,  15  in  an  orphan  asjdum,  and  40 
in  State  prisons. 

The  history  of  the  "  Jukes,"  already  mentioned,  and  that  of  the 
Kallikak  family,  f  may  also  be  referred  to  in  this  connexion.  The 
latter  has  recently  been  traced  and  fully  described  in  detail  by  Dr. 
Goddard,  and  his  study  is  well  worth  perusal,  as  showing  the 
hereditary  nature  and  sociological  bearings  of  feeble-mindedness. 
A  certain  Martin  Kallikak  married  in  1837.  Both  he  and  his  \%ife 
were  normal,  and  their  descendants  for  six  generations,  numbering 
several  hundreds  of  individuals,  were  traced  by  Dr.  Goddard,  and 
were  also  normal.  But  Martin  KaUikak  had  an  illegitimate  child 
by  a  girl  who  was  feeble-minded,  and  the  descendants  along  this 
line  in  about  the  same  number  of  generations  who  were  hving 
under  the  same  environment  in  the  same  State  yielded  no  less  than 
222  feeble-minded  offspring  out  of  forty-one  matings. 

*  A.  H.  Eastabrook  and  C.  B.  Davenport,  "  The  Xam  Family,"  August,. 
1912. 

j   H.  H.  Goddard,  "  The  KaUikak  Family,"  1912. 


Illegitimacy  45 1 


niegitimacy. 

This  subject  is  intimately  related  to  that  of  the  propagation  of 
aments.  What  proportion  of  aments  are  illegitimate  and  what  pro- 
portion of  mentally  deficient  persons  produce  illegitimate  children, 
I  do  not  know,  but  certainly  the  number  must  be  very  considerable, 
as  will  be  apparent  from  some  statistics. 

As  a  result  of  inquiries  made  in  the  years  1902-1904  of  the  Mag- 
dalen Homes  in  England,  to  which  100  homes  sent  repUes,  it  was 
found  "  that  14,725  inmates  had  passed  through  the  homes  in  that 
period,  and  that  of  these  2,521,  or  about  16  per  cent.,  were  returned 
as  feeble-minded.  Of  this  number,  588,  or  25  per  cent.,  had  one 
illegitimate  child,  and  198,  or  8  per  cent.,  were  known  to  have  had 
more  than  one,  making  a  total  of  786,  or  33  per  cent.,  mothers  of 
illegitimate  children  among  the  feeble-minded  inmates."*  But 
there  is  every  reason  to  think  that  these  figures  are  below  the 
actual  number,  owing  to  the  absence  of  direct  medical  evidence 
regarding  the  mental  condition  of  the  inmates;  and  Dr.  Potts  says 
that  of  100  consecutive  cases  admitted  into  the  ]\Iagdalen  Home  at 
Birmingham,  26  were  feeble-minded,  7  were  cases  of  m^oral  insanity, 
I  was  epileptic,  i  w^as  lunatic,  and  i  was  deaf  and  dumb.  I  have 
had  the  opportunity  of  examining  practically  every  case  admitted 
to  one  of  these  homes  during  the  past  five  or  six  years,  and  I  have 
a  knowledge  of  the  inmates  of  several  others,  and  I  should  put  the 
proportion  of  mental  defectives  among  them  at  quite  40  per  cent. 
of  the  total  inmates.  Returns  obtained  by  the  Preventive  Com- 
mittee of  the  National  Vigilance  Society,  as  a  result  of  special 
inquiries  of  203  Boards  of  Guardians,  show  that,  during  the  year 
1889,  715  weak-minded  women  passed  through  105  workhouses, 
whilst  at  56  workhouses  it  was  stated  that  the  approximate  number 
of  such  women  who  were  leading  immoral  lives  was  366. 

The  following  particulars  were  ascertained  by  the  medical  in- 
vestigators appointed  by  the  Royal  Commission.  They  relate 
entirely  to  feeble-minded  females,  and  chiefly  to  inmates  of  work- 
house maternity  wards :  . 

In  Manchester,  Dr.  Melland  found  that,  out  of  94  women  in  these 
wards,  19  were  feeble-minded,  all  the  children  except  two  being 
illegitimate.  On  making  further  inquiries  of  some  of  the  younger 
*  Report  of  Royal  Commission  on  Feeble-minded,  vol.  viii.,  p.  175. 


452  Sociology 

of  the  other  167  feeble-minded  women  in  the  house,  it  was  ascer- 
tained that  another  13  admitted  having  given  birth  to  illegitimate 
children,  and  Dr.  Melland  states  that  these  inquiries  were  only  of 
a  partial  and  incomplete  nature. 

In  Birmingham,  Dr.  Potts  found  that  4  out  of  the  34  women  in 
the  maternity  wards  were  mentally  defective,  whilst  at  Stoke-on- 
Trent  the  same  observer  found  that,  of  the  17  women  giving  birth 
to  children  during  the  period  of  inquiry,  7  were  feeble-minded,  all 
the  children  being  illegitimate.  Dr.  Potts  ascertained  that  the 
total  progeny  resulting  from  16  mentally  defective  women  was  no 
less  than  116.  In  the  lock  wards  he  found  5  feeble-minded  women, 
all  of  whom  were  prostitutes. 

In  the  rural  districts  the  state  of  affairs  was  even  worse.  In 
Wiltshire,  Dr.  Pearse  found  that,  of  58  feeble-minded  women  in 
the  workhouse,  18  had  given  birth  to  illegitimate  children.  In 
Nottinghamshire,  Dr.  Gill  ascertained  that  11  out  of  23  of  these 
women  had  borne  illegitimate  children.  In  Carnarvon,  Dr.  Parry 
found  that  half  the  inmates  of  the  maternity  wards  were  mentally 
defective,  nearly  all  the  children  being  illegitimate ;  whilst  in  Somer- 
setshire I  ascertained  that  fully  half  of  the  women  admitted  into 
the  workhouse  to  be  confined  during  the  previous  five  years  had 
been  feeble-minded;  further,  that  out  of  all  the  feeble-minded 
women  in  the  area  (167),  nearly  two-fifths  (61)  had  given  birth  to 
children,  two-thirds  of  whom  were  illegitimate. 

It  should  be  remarked  that  in  few  cases  is  the  propagation 
by  these  women  limited  to  a  single  child.  More  often  their  off- 
spring number  three  or  four,  and  one  feeble-minded  woman  whom 
I  saw  had  given  birth  to  six  illegitimate  children.  All  of  these 
were  by  different  fathers,  and  she  was  confined  of  each  one  in  the 
workhouse.  I  may  add  that  I  discovered  one  feeble-minded  woman 
in  a  workhouse  who  had  given  birth  to  four  illegitimate  children, 
although  she  had  never  left  the  precincts  of  the  house. 

When  it  is  remembered  that  these  figures  only  relate  to  a  rela- 
tively small  portion  of  the  country,  and  that  the  investigations 
only  extended  over  a  period  of  about  three  months,  it  is  clear  that 
the  number  of  children  produced  every  year  throughout  England 
and  Wales  by  feeble-minded  women  must  be  very  great.  In  some 
cases  the  mothers  have  pronounced  erotic  tendencies,  and  many 
of  them  seem  to  be  utterly  lacking  in  any  sense  of  shame,  modesty, 
ro  9ven  ordinary  decency;  but  even  the  best-behaved,  and  those 


Illegitimacy  453 

of  good  parentage  brought  up  amid  every  refinement,  are  often  so 
facile  that  it  is  utterly  unsafe  for  them  to  be  at  large  without 
protection. 

As  bearing  upon  the  questions  of  propagation  and  the  social 
relationship  of  the  ament,  I  may  cite  the  following  cases  which 
hsive  come  within  my  own  experience : 

Upon  the  edge  of  a  moor,  in  a  thinly  inhabited  part  of  the  West 
Countr}',  stands  a  filthy  thatched  wooden  hovel  consisting  of  two 
rooms.  Its  exterior  has  an  air  of  utter  desolation  and  neglect;  its 
interior  is  in  a  state  of  indescribable  dirt  and  confusion.  It  is 
occupied  by  a  married  couple  and  their  family.  The  man,  aged 
fifty  years,  is  of  a  decidedly  low  animal  type,  and  has  considerable 
moral,  as  well  as  slight  mental,  defect.  He  never  refuses  a  drink, 
and  picks  up  a  living  by  occasional  osier-stripping,  and  doing  odd 
jobs  on  farms,  but  chiefly,  I  think,  by  poaching.  The  woman,  his 
wife,  is  forty-four  years  of  age  and  feeble-minded.  She  seems  to 
be  busy  most  of  the  day,  and  in  her  way  keeps  the  house  going; 
but  she  is  utterly  lacking  in  any  capacity  for  management,  and  the 
filth  and  disorder  are  extreme.  This  woman  had  three  children 
before  marriage,  and  nine  since.  Of  the  former  three,  one  died 
young  of  consumption,  a  second  has  entirely  disappeared,  and  the 
third  lives  about  the  neighbourhood;  but  he  quarrelled  with  his 
mother's  husband,  and  they  are  not  now  on  speaking  terms.  Of 
the  nine  born  in  wedlock,  two  died  in  infancy,  three  attend  the 
village  school  and  are  mentally  defective,  and  another  also  mentally 
defective  is  at  home.  The  eldest  does  odd  jobs  with  his  father, 
and  seems  to  be  able  to  take  care  of  himself.  The  remaining  two 
are  aged  five  months  and  three  years  respectively,  and  are  too 
young  to  enable  an  opinion  to  be  formed  as  to  their  mental  capacity. 
To  this  it  may  be  added  that  the  father  has  had  ten  children  by  a 
previous  wife.  Of  these,  two  are  feeble-minded,  one  of  whom  is 
living  a  life  of  prostitution,  and  has  already  had  two  illegitimate 
children  in  the  workhouse.  The  others  have  been  entirely  lost 
sight  of. 

Mary  H is  a  feeble-minded  married  woman  forty  years  old. 

She  lives  with  her  husband,  a  farm  labourer,  in  a  small  cottage  in 
an  isolated  village.  She  is  industrious  and  always  working,  but 
the  house  is  in  a  disgraceful  muddle.  At  my  visit  there  were  two 
unwashed,  partially  dressed  children,  under  three  years  of  age, 
sprawling  about  the  wet  stone  floor  amid  a  litter  of  dirty  plates 


454  Sociology 

and  pans,  potato  peelings,  and  live  poultry.  Upon  asking  her  how 
old  she  was,  and  how  long  she  had  been  married,  she  replied,  with 
a  fatuous  smile,  that  she  didn't  know,  but  her  mother  did.  The 
children  I  saw  in  the  house  were  too  young  to  examine  mentally; 
but  two  other  illegitimate  children  whom  I  did  see,  aged  sixteen 
and  seventeen  years  respectively,  were  feeble-minded.  Both  of 
these  are  industrious  boys,  and  work  well  under  supervision,  but 
they  are  quite  incapable  of  looking  after  their  affairs.  This  woman 
has  two  brothers,  who  are  also  feeble-minded;  one  is  constantly  in 
and  out  of  the  workhouse,  but  the  other,  aged  thirty,  is  employed 
regularly  with  a  farmer  at  the  rate  of  a  shilling  a  day.  Their 
mother  has  had  several  attacks  of  insanity,  but  the  father  is  dead, 
and  no  particulars  were  obtainable  regarding  him. 

Rose  D is  a  feeble-minded  woman  forty-five  years  of  age. 

She  is  the  daughter  of  a  well-to-do  farmer,  but  ran  away  from  home 
at  the  age  of  twenty  years,  and  since  then  she  has  been  living  a  life 
of  prostitution.  Her  usual  abode  is  the  common  lodging-house, 
but  a  considerable  part  of  her  life  has  been  spent  in  prison,  the 
workhouse,  and  various  charitable  homes.  She  has  been  confined 
of  three  illegitimate  children  in  the  workhouse.  The  clergyman  of 
the  parish  in  which  she  lives  says  that  he.  has  got  her  into  homes 
again  and  again,  but  she  will  not  stay,  and  they  cannot  compel 
her  to  do  so.  All  attempts  to  induce  her  to  lead  a  respectable  life 
have  failed,  and  she  is  his  despair  and  "  a  disgrace  to  the  civiliza- 
tion which  permits  her  to  be  at  large." 

I  may  add  that  these  are  by  no  means  isolated  instances.  I 
have  known  cases  in  which  feeble-minded  girls  have  been  actually 
exploited  by  their  own  mothers  for  immoral  purposes,  and  many 
of  the  particulars  regarding  this  matter  which  have  come  under 
my  own  notice  are  too  revolting  for  publication,  and  show  in  the 
clearest  manner  that  the  propagation  by  aments  is  both  a  terrible 
and  extensive  evil. 


REMEDIAL  MEASURES. 

I  think  it  will  be  apparent  from  the  foregoing  remarks  that  the 
condition  of  mental  deficiency  is  one  which  is  attended  with  most 
important  and  far-reaching  social  consequences.  Indeed,  the 
economic  disability,  the  antisocial  propensities,  and  the  rate  of 
propagation  of  these  persons,  combine  to  constitute  a  problem  of 


Remedial  Measures  455 

a  magnitude  that  no  civilized  country  can  afford  to  neglect,  either 
in  the  interests  of  the  defectives  themselves,  or  in  those  of  the 
general  community.  I  do  not  propose  to  enter  into  any  detailed 
discussion  as  to  the  solution  of  this  problem,  but  there  are  a  few 
points  to  which  it  will  not  be  out  of  place  to  refer. 

And  first  of  all  we  may  dismiss  the  suggestion  of  a  "  lethal 
chamber,"  I  do  not  say  that  society,  in  self-defence,  would  be 
unjustified  in  adopting  such  a  method  of  ridding  itself  of  its  anti- 
social constituents.  There  is  much  to  be  said  both  for  and  against 
the  proposal,  but  it  is  so  clearly  impracticable  in  the  present  state  of 
public  opinion  that  it  need  not  be  considered.  We  have  to  recog- 
nize that  mental  defectives  exist,  and  must  be  allowed  to  exist, 
and  the  questions  before  us  are  as  to  the  way  in  which  the  State 
can  best  deal  with  them,  and  the  manner  in  which  it  can  prevent 
their  procreation. 

Training. — We  have  seen  that,  in  spite  of  the  great  expense  of 
time  and  money  spent  upon  the  training  of  defectives,  their  economic 
value  remains  exceedingly  small;  and  this,  together  with  the  fact 
that  the  defect  can  never  be  cured,  that  these  persons  can  never 
really  become  self-dependent,  raises  the  question  as  to  whether 
such  training  is  justifiable.  In  spite  of  the  results  hitherto  obtained, 
I  believe  it  is,  I  fully  recognize  that  we  must  avoid  the  danger  of 
this  training  becoming  a  fashionable  fad,  and  being  carried  to  an 
extent  out  of  all  proportion  to  the  results  likely  to  be  achieved — 
that,  in  fact,  not  only  must  the  ament  be  sheltered  from  the  neglect 
or  adverse  competition  of  society,  but  that  society  and  the  rate- 
payer must  be  protected  against  the  ament.  I  believe,  however, 
that  both  these  ends  are  best  attained  by  suitable  training,  and  that 
the  withholding  of  such  is  not  only  injurious  to  the  individual 
ament,  but  constitutes  a  danger  to  the  State,  besides  being  an 
economic  blunder. 

Supervision. — The  fault  of  our  present  method  lies  not  so  much  in 
the  training  as  in  the  absence  or  inadequacy  of  suitable  after-care. 
We  have  been  content  to  spend  large  sums  of  money  upon  the  educa- 
tion of  these  persons — I  am  now  speaking  of  the  mildest  grade — 
to  place  them  in  situations,  and  then  to  assume  that  they  were  quite 
capable  of  shifting  for  themselves ;  and  it  is  to  the  neglect  to  provide 
adequate  supervision  during  adolescence  and  later  life  that  we  must 
attribute  much  of  the  evil  which  has  been  described  in  the  pre- 
ceding pages. 


45  6  Sociology 

The  fact  is,  that  although  training  will  certainly  do  much  to 
repress  the  growth  of  vicious,  criminal,  and  insane  tendencies,  and 
will  render  the  mildest  grades  of  defect  capable  of  remunerative 
employment,  or  even  of  earning  a  living,  this  can  only  be  so  "  under 
favourable  circumstances."  Competition  with  the  normal  popula- 
tion is  impossible,  and,  as  a  result  of  the  Workmen's  Compensation 
and  Employers'  Liabilitj^  Acts,  employment  is  becoming  more  and 
more  difficult  to  obtain  for  these  persons.  Not  only  must  work 
suited  to  their  capacity  be  found  for  them,  but  in  the  great  majority 
of  cases  the  wages  so  earned  must  be  laid  out,  and  a  general  super- 
vision exercised  over  their  whole  behaviour,  just  as  in  the  case  of 
children.  Provided  this  be  done,  the  time  and  mone}^  spent  on 
training  will  be  well  repaid,  and  will  result  in  the  transformation 
of  useless,  and  even  dangerous,  individuals,  into  useful  happy,  and 
contented  members  of  society.  Failing  this  supervision,  however, 
aments,  whether  trained  or  otherwise,  will  certainly  degenerate, 
and  will  inevitably  swell  the  population  of  our  asylums,  prisons, 
and  workhouses.  In  the  case  of  females,  it  is  tolerably  certain 
that  even  before  this  can  happen  the  blight  will  have  been  passed 
on  to  a  new  generation. 

It  would  be  beyond  the  purpose  of  this  work  to  enter  into  any 
discussion  as  to  the  precise  nature  of  this  supervision,  and  un- 
doubtedly this  must  varj^  with,  and  be  dependent  upon,  the  habits, 
propensities,  capacity,  and  character  of  each  individual.  Any 
method  of  administration  which  does  not  take  these  into  account, 
and  which  attempts  to  provide  for  mental  defect  in  the  abstract, 
cannot  be  an  economic  success.  Brief!}',  we  may  say  that  to  be 
satisfactory  the  provision  for  each  individual  must  be  of  such  a 
nature  as  to  (i)  adequate^  safeguard  the  interests  of  society  against 
the  special  peculiarities  of  the  ament ;  (2)  protect  the  ament  against 
the  evil  suggestions  and  pernicious  influence  of  certain  sections  of 
society,  and  at  the  same  time  ensure  him  kindly  treatment ;  (3)  utilize 
his  working  capacit}-  to  the  fuhest  and  most  remunerative  extent, 
so  that  the  cost  of  provision  falls  as  lightly  as  possible  upon  an 
already  overburdened  ratepayer.  In  general,  these  three  condi- 
tions will  best  be  fulfiUed  b}'  compulsor}-  detention  in  suitable 
colonies  or  institutions;  but  for  some  cases  guardianship  or  over- 
sight without  detention,  as  proposed  by  the  Royal  Commission, 
will  be  adequate.  The  provisions  of  the  Mental  Deficiency  Act  of 
1913  should  undoubtedl}'   do  much  to  minimize  the  evils  which 


The   Prevention  of  Propagation  457 

have  resulted  from  the  neglect  to  afford  adequate  supervision  in 
the  past,  and  they  mark  a  distinct  step  in  the  right  direction. 

The  Prevention  of  Propagation. 

The  next  important  question  is  that  of  procreation.  We  have 
seen  that  aments  are  being  produced  at  a  rate  which  can  only  be 
described  as  alarming.  This  is  due  in  part  to  the  propagation  by 
persons  who  are  themselves  mentally  deficient,  in  part  to  the  rela- 
tively increased  fertility  of  persons  who,  whilst  not  actually  aments, 
are  of  pronounced  psychopathic  inheritance.  The  result  is  to  bring 
about  an  increasing  ratio  of  the  mentally,  physicall3^  and  socially 
unfit,  which,  if  unchecked,  must  not  only  handicap  social  progress, 
but  which  may  hurl  the  State  into  the  abyss  of  degeneracy.*  For 
it  is  to  be  borne  in  mind  that  the  psychopathic  do  not  mate  only 
amongst  themselves.  They  intermarry  with  the  hitherto  untainted 
and  normal  members  of  the  community,  and  in  so  doing  constantly 
drag  fresh  blood  into  the  vortex  of  disease.  To  check  this  evil, 
three  methods  have  been  proposed,  to  which  we  may  briefly  refer. 
They  are — (i)  Asexualization  ;  (2)  compulsory  segregation  during  the 
reproductive  age  ;  and  (3)  the  regulation  of  marriage. 

Asexualization. — As  formerly  practised,  this  consisted  in  the 
operations  of  castration  and  ovariotomy;  but  these  have  now  been 
superseded  by  those  of  vasectomy  and  salpingectomy.  The  operation 
of  vasectomy  is  quite  simple,  and  the  experience  of  some  hundreds  of 
cases  shows  that  there  is  no  atrophy  of  the  testicles,  no  secondary 
mental  or  o'ther  changes,  and  no  unfavourable  symptoms.  The 
operation  in  the  female  is  naturally  somewhat  more  serious,  but 
even  this  can  now  be  performed  without  risk,  and  it  appears  quite 
conclusive  that  the  effect  in  both  male  and  female  is  merely  to 
produce  sterility  without  loss  of  desire  or  any  other  untoward 
results.  In  Americaf  these  operations  have  now  been  performed 
upon  many  hundreds  of  cases,  both  male  and  female,  and  it  is  con- 
tended that  by  their  means,  in  addition  to  being  rendered  sterile, 
many  aments  have  been  cured  of  depraved  and  bestial  propensities, 

*  On  this  subject,  see  an  article  by  the  author  on  "  Eugenics  "  in  the 
Quarterly  Review,  July,  1912. 

t  For  an  account  of  some  recent  American  legislation  regarding  steriliza- 
tion, see  "  Proposed  Sterilization  of  Certain  Degenerates,"  by  Dr.  R.  R. 
Rentoul,  The  Therapist,  September  15,  1910;  also  a  very  interesting  article 
by  Dr.  S.  A.  Bontor  dealing  with  marriage  and  steriUzation  in  the  Medical 
Press.  August  18,  1909. 


45  8  Sociology 

and  their  general  behaviour  much  improved.  I  do  not  doubt  that 
there  are  persons,  not  necessarily  aments,  upon  whom  the  per- 
formance of  this  operation  is  not  only  justifiable,  but  advisable;* 
but  the  enforced  sterilization  of  all  psychopathies  is  quite  out 
of  the  question,  and  the  only  aspect  of  the  matter  we  need  con- 
sider is  that  of  the  wholesale  adoption  of  these  operations  as  a 
means  of  preventing  propagation  by  aments.  My  own  opinion  is 
that,  whilst  being  of  service  in  particular  cases,  it  must  be  a  work 
of  supererogation  in  the  majority.  It  seems  to  be  forgotten  that, 
although  it  will  prevent  these  persons  propagating,  it  will  not 
make  a  mental  defective  competent,  a  pauper  independent,  an 
inebriate  sober,  or  a  criminal  moral.  In  the  great  majority  of 
aments  supervision  and  segregation  will  still  be  called  for  on  account 
of  personal  traits,  and  it  is  futile  to  think  that  these  persons  can  be 
turned  loose  upon  society  merely  because  they  have  been  sterilized. 
In  any  event,  present  public  opinion  in  England  is  so  far  from 
being  ripe  for  any  such  proposal  that  it  may  be  regarded  as  outside 
the  field  of  practical  politics. 

Segregation. — Where  the  effective  supervision  of  aments  cannot 
be  secured  by  other  methods,  then  it  seems  to  me  that  their  segrega- 
tion in  suitable  colonies  affords  the  best  practical  means  at  our 
disposal  for  at  once  securing  the  kindly  care  of  the  mentally  de- 
ficient, their  useful  and  profitable  employment,  and  the  restriction 
of  their  propagation.  In  the  original  draft  of  the  Mental  Deficiency 
Bill  there  was  a  clause  empowering  the  detention  of  those  "  in 
whose  case  it  is  desirable  that  they  should  be  deprived  of  the  oppor- 
tunity of  procreating  children."  This,  of  course,  would  have  had 
to  be  accompanied  by  efficient  safeguards,  but  such  would  not  be 
difficult  to  devise,  and  it  can  only  be  regarded  as  unfortunate  for 
the  nation  that  an  outburst  of  hysterical  sentiment  should  have 
caused  the  clause  to  be  abandoned.  It  is  the  experience  of  aU 
who  have  had  to  do  with  aments  that  they  are  not  only  safer  and 
more  useful,  but  also  much  happier,  in  a  suitable  institution  afford- 
ing the  companionship  of  their  compeers. 

Regulation  of  Marriage. — By  this  meant  the  prohibition  by 
law  of  the  marriage  of  those  persons  who  are  likely  to  produce 
degenerate    offspring.     Such     persons     fall    into    two    classes^ 

*  For  some  remarks  as  to  cases  in  which  steriUzation  is  advisable,  see  a 
paper  by  the  author,  "  Some  Medical  Aspects  of  Eugenics/'  Medical  Press, 
July  31  and  August  7,  1912. 


The  Prevention   of  Propagation  459 

(i)  Those  who  are  in  themselves  mentally  defective  or  otherwise 
abnormal;  and  (2)  those  who,  whilst  not  being  defective,  come  of 
a  pronounced  psychopathic  stock.  With  regard  to  actual  aments, 
it  is,  in  my  opinion,  utterly  illogical  and  absurd  to  permit  a  class 
to  enter  into  a  marriage  contract  the  mildest  members  of  which 
are  defined  by  Act  of  Parliament  as  suffering  from  a  degree  of 
defect  "  so  pronounced  that  they  require  care,  supervision,  and 
control  for  their  own  protection  or  for  the  protection  of  others." 
It  may  be  that  legal  prohibition  would  only  partially  check 
their  propagation,  because,  as  we  have  seen,  a  considerable  number 
of  their  offspring  are  illegitimate;  but  that  considerable  benefit  to 
the  State  would  result  cannot  be  doubted,  and  in  view  of  the  in- 
complete protection  afforded  to  the  ament  and  to  society  by  the 
Act  of  1913  I  regard  it  as  deplorable  that  the  clause  in  the  original 
draft  of  this  Bill  was  omitted.  This  clause  made  it  a  misdemeanour 
for  any  person  to  intermarry  with,  or  attempt  to  intermarry  with, 
or  to  solemnize  or  procure  or  connive  at  the  marriage  of,  a  defective 
within  the  meanmg  of  the  Act. 

The  case  of  those  persons  who  are  not  aments,  but  who  suffer 
or  have  suffered,  from  insanity,  epilepsy,  or  other  disorder  of  mind, 
stands  on  a  somewhat  different  footing;  but  even  here  I  see  no 
reason  why  their  marriage  in  certain  instances  should  not  be  for- 
bidden by  law.  If  the  prohibition  did  not  avail  entirely  to  check 
their  propagation,  it  would  do  something  in  this  direction,  and  it 
would  certainly  be  a  great  factor  in  the  education  of  public  opinion 
regarding  the  responsibility  of  marriage.  Were  this  responsibility 
more  fully  realized,  and  greater  care  taken  in  inquiring  into  the 
health  and  antecedents  of  the  contracting  parties,  we  should  hear 
very  much  less  about  the  need  for  reform  in  the  law  of  divorce. 
Laws  of  this  kind  already  exist  in  some  European  countries  and  in 
several  of  the  States  of  America,  and  although  it  is  difficult  to 
obtain  definite  information  as  to  their  working,  and  opinions  differ 
somewhat  regarding  their  value,  there  seems  to  be  little  doubt 
that  on  the  whole  they  have  been  productive  of  good,  and  have 
not  only  helped  to  educate  the  conscience  of  the  community,  but 
have  prevented  many  undesirable  persons  from  getting  married.* 

*  For  the  most  recent  and  complete  account  of  American  marriage  regu- 
lations, laws  concerning  sterilization,  the  prohibition  of  the  entrance  of 
immigrants,  together  with  an  extensive  bibliography  of  the  whole  subject,  see 
"  Die  Rassenhygiene  in  den  Vereinigten  Staaten  von  Nordamerika,"  by 
G.  von  Hoffman,  Austrian  Vice-Consul  in  California.     Munich,  191 3. 


460  Sociology 

Lastly,  we  may  briefly  consider  the  much  larger  and  more  far- 
reaching  question  of  the  prohibition  of  the  marriage  of  those  persons 
who  may  not  in  themselves  evince  serious  mental  abnormality,  but 
who  yet  come  of  a  pronounced  psychopathic  stock,  and  who  may 
transmit  the  germinal  impairment  to  their  descendants.  The 
genealogical  inquiries  which  have  been  made  in  recent  years  amply 
demonstrate  the  existence  of  a  class  in  whom,  although  the  taint  is 
latent,  it  is  nevertheless  present,  and  transmissible  to  subsequent 
generations.  It  is  clearly  within  the  province  of  social  science  to 
consider  whether  the  laws  of  heredity  may  not  be  utilized  in  the 
formulation  of  such  regulations  regarding  marriage  as  would  not 
only  check  the  propagation  of  these  germinally  tainted,  but  would 
encourage  that  of  the  germinally  healthy,  and  so  secure  the  bio- 
logical advance  of  the  race.  That  the  biological  fitness  of  its 
citizens  must  be  a  matter  of  prime  concern  to  any  community 
cannot  be  questioned.  In  former  days  it  was  secured  by  the 
operation  of  natural  selection,  but  this  has  been  to  a  very  great 
extent  thwarted  and  neutralized  by  progress  in  the  art  of  medicine 
and  by  the  development  of  a  sentiment  which  tends  to  consider 
the  individual  before  the  race,  with  the  result  that  the  problem  of 
the  unfit  is  now  assuming  serious  proportions  in  all  civilized  com- 
munities. 

For  my  own  part,  I  am  convinced  that  the  nation  which  wishes 
to  escape  degeneracy  will  sooner  or  later  have  to  give  serious 
attention  to  the  matter  of  the  innate  constitution  of  its  citizens, 
and  the  manner  in  which  that  innate  condition  may  be  controlled 
by  laws  concerning  marriage.  Nevertheless,  I  do  not  think  that 
any  legislation  on  these  lines  is  possible  at  present,  for  two  reasons : 
Firstly,  because  the  laws  regarding  hereditary  transmission  are  not 
sufficiently  known;  and,  secondly,  because  we  have  no  data  regard- 
ing the  antecedents  of  the  mass  of  the  people. 

With  regard  to  the  first  of  these,  the  defect  is  rapidly  being 
remedied,  and  the  researches  which  are  now  being  carried  out  in 
both  hemispheres  leave  little  room  for  doubt  that  reliable  know- 
ledge will  soon  be  forthcoming  concerning  the  rules  governing 
hereditary  transmission.  With  regard  to  the  second  desideratum, 
progress  is  much  less  marked,  and  although  it  is  perfectly  true  that 
many  of  the  more  enlightened  members  of  the  country  are  now 
paying  attention  to  their  genealogical  tree  from  the  biological 
aspect,  there  is  a  complete  absence  of  records  in  the  case  of  the 


The   Prevention  of  Propagation  461 

great  bulk  of  the  community.  It  was  this  defect  which  caused  me 
some  time  ago  to  advocate  the  estabhshment  of  a  S3'stem  of  national 
famih^  records,*  which  I  think  must  be  an  essential  prelude  to  any 
useful  legislation  regarding  marriage. 

But  although  the  facts  at  present  available  are  not  sufficient  to 
justif}'  legislation,  there  are  many  cases  in  which  the  experienced 
physician  is  quite  able  to  give  a  reliable  opinion  as  to  whether  the 
offspring  of  a  particular  union  is  likely  to  be  healthy  or  the  reverse. 
It  is  true  that  the  advice  given  is  not  always  followed,  but  the  fact 
that  it  is  sought,  and  in  my  experience  increasingly  sought,  is 
evidence  of  the  development  of  a  conscience  on  the  subject,  and  I 
hold  that  it  is  certainly  the  duty  of  the  medical  profession  to  be 
prepared  to  give  advice  in  the  matter. 

But  the  medical  profession  has  a  still  higher  duty.  It  is  to  our 
profession  that  the  State  looks  for  advice  and  help  regarding  the 
future  health  of  the  State,  and  I  consider  it  to  be  at  once  our  privi- 
lege and  responsibility  to  speak  on  this  subject  of  the  propagation 
of  the  germinally  unfit  in  clear  and  unmistakable  terms,  and  so 
help  to  form  this  public  conscience. 

So  long  as  we  are  content  to  raise  no  voice  against  the  marriage 
of  the  diseased,  the  degenerate,  the  habitual  criminal,  and  the 
chronic  pauper,  and  are  willing  to  educate,  feed,  clothe,  and  ulti- 
mately pension  as  many  offspring  as  these  persons  see  fit  to  pro- 
duce ;  so  long  as  legislation  is  permitted  a  free  hand  in  doing  every- 
thing calculated  to  diminish  parental  and  social  responsibility  and 
to  strike  at  the  very  root  of  any  incentive  to  labour;  so  long  as 
our  law-makers  and  would-be  philanthropists  are  blind  to  the  folly 
of  transferring  the  burdens  and  penalties  inevitably  following  care- 
lessness, improvidence,  indifference,  drunkenness,  and  unhmited 
selfishness,  from  the  shoulders  of  those  upon  whom  they  should 
rightly  fall  to  the  careful,  provident,  and  industrious  members  of 
the  State — then  so  long  will  these  classes  (and  these  qualities)  con- 
tinue to  be  perpetuated,  and  their  numerical  ascendancy  is  simply 
a  question  of  time. 

It  cannot  be  other  than  gratifying  to  those  who  have  the  welfare 
of  their  country  at  heart  to  find  that  public  regard  is  at  length 
being  focussed  upon  this  question.  Many  years  ago  the  observa- 
tions of  Francis  Galton  led  him  to  see  the  possibilities  for  good  or 

*  A.  F.  Tredgold,  "  Marriage  Regulation  and  National  Family  Records," 
Eugenics  Review,  April,  191 2. 


462  Sociology 

ill  which  might  be  exerted  by  social  science  acting  in  the  way  I 
have  indicated.  To  him  must  be  attributed  the  modern  enunciation 
of  the  science  of  eugenics,  which  he  defined  as  "  the  study  of  agencies 
under  social  control  that  may  improve  or  impair  the  racial  qualities 
of  future  generations  either  physically  or  mentally  ";  and  it  is  in 
the  study  and  application  of  these  principles  that  we  shall  find  the 
antidote  to  degeneracy  and  the  true  road  to  racial  progress. 

Finally,  we  have  to  look  beyond  measures  designed  to  check 
the  perpetuation  of  an  existing  taint,  and  to  consider  how  it  may 
be  prevented  at  its  source;  how  we  may  obviate  that  initial  ger- 
minal impairment  in  which  lies  the  prime  origin  of  defect,  and  much 
of  the  disease,  of  mind.  The  causes  of  germinal  variation,  whether 
retrogressive  or  progressive,  axe  very  imperfectly  known,  and  there 
is  urgent  need  of  their  study.  My  own  observations  have  led  me 
to  the  conclusion  that  they  are  to  be  found  in  the  environment, 
using  this  term  in  its  widest  sense,  and  that  the  psj^chopathic 
diathesis  which  reaches  its  culmination  in  amentia  is,  at  the  be- 
ginning, dependent  upon  disease  or  disorder  of  metabolism  induced 
by  external  causes  and  faulty  modes  of  life.  It  is  probable  that 
manj^  of  these  adverse  influences  pass  unrecognized,  and  that  they 
vary  with  different  social  conditions;  but  the  chief  of  them  to-day 
would  appear  to  be  chronic  alcoholism,  tuberculosis,  syphilis,  and 
the  hurry  and  scurry,  wdth  all  their  attendant  stress,  excess,  and 
dissipation,  of  modern  life.  The  evolution  of  society  has  outstripped 
the  evolution  of  the  race,  with  the  result  that  a  disharmony  has 
been  produced  which  now  reveals  itself  in  various  manifestations 
of  germinal  impairment. 

According,  therefore,  as  we  diligently  seek  out  and  conform  to 
the  laws  of  health,  and  as  we  improve  the  manner  of  Hving,  the 
moral,  mental,  and  physical  fibre,  and  the  general  well-being  of 
our  people,  so  shall  we  be-  successful  in  preventing  disease  of  mind, 
and  it  is  to  those  entrusted  with  its  present  and  future  welfare  that 
the  nation  must  look  to  enforce  these  principles  by  wise  legislative 
enactments. 


APPENDIX 


463 


NOMENCLATURE 

The  multiplicity  of  terms  which  are  applied  to  the  genus  and  the 
different  grades  of  mental  defect  is  a  source  of  no  little  confusion, 
and  hence  it  is  hoped  that  the  accompanying  Table  of  Synonyms 
may  not  only  help  to  make  the  nomenclature  of  this  condi- 
tion somewhat  clearer,  but  may  be  of  service  to  those  desiring  to 
consult  foreign  literature.  It  is  necessary  to  point  out,  however, 
that  many  foreign  terms  are  used  so  loosely,  and  often  in  such  a 
contradictory  fashion,  that  it  is  frequently  no  easy  matter  to 
assign  their  precise  English  equivalents ;  but  so  far  as  I  can  ascertain 
from  my  own  reading,  their  meaning  is  as  shown  in  the  table,  and 
this  is  in  general  accord  with  the  views  of  Dr.  Shuttleworth,  Dr. 
R.  Langdon  Down,  and  Dr.  G.  A.  Auden,  who  have  most  kindly 
given  me  the  benefit  of  their  experience  on  this  matter. 

It  will  be  seen  that  with  regard  to  the  conditions  of  idiocy, 
imbecility,  and  moral  imbecility,  the  terms  are  practically  identical, 
all  of  them  being  derivatives  of  idios  and  imbecillus  respectively. 
At  the  same  time  it  is  to  be  remarked  that  these  words  are  not 
always  used  in  this  precise  sense  (as  indicative  of  a  definite  grade 
of  amentia),  but  are  still  sometimes  applied  to  aments  in  general, 
or  even  to  various  stages  of  dementia.  Thus,  I  have  even  heard 
English  asylum  medical  officers  speak  of  the  mental  weakness 
resulting  from  insanity  as  "  imbecility  "  and  "  idiocj^"  It  need 
hardly  be  said  that  such  use  of  these  terms  is  to  be  deprecated  as 
liable  to  lead  to  no  little  misunderstanding. 

With  regard  to  the  general  condition,  the  usual  English  generic 
word  is  mental  deficiency  (or,  in  medical  and  scientific  works, 
amentia),  although  the  whole  class  are  not  infrequently  included 
under  the  term  the  feeble-minded  {e.g.,  The  Royal  Commission  on 
the  Feeble-minded).  Since,  however,  this  latter  term  is  really  a 
more  specific  one,  it  seems  better  that  it  should  be  restricted  to  the 
mildest  grade  of  aments,  and  this,  as  a  matter  of  fact,  is  the  more 

464 


A   TABLE 


1. 


z' Condition  ^ 


Generic  term,  compre- 
hending all  grades  of 
arrested  or  imperfect 
mental  development 
from  birth,  or  from  an 
early  age.  (For  defini- 
tion, see  p.  8.) 


Persons 


2. 

Low  -  grade         (severest) 
Amentia.      (For  defini--, 
tion,  see  p.  94.) 


Condition-! 


Persons 


3. 


f  Condition-! 


Medium  -  grade    Amentia.) 

(For       definition,      seel  ^ 

p.  93.)  I  Persons     I 


4. 

High  -  grade  .  (mildest) 
Amentia.  (For  defini- 
tion, see  p.  91.) 


Condition  J 


5. 

The  lowest  grade  0! 
mental  development 
among  the  normal — 
(i.e.,  non  -  defective) — 
population. 


.Persons     " 


'Condition] 
I^Persons 


6. 

{Condition- 
Persons     -| 


ENGLISH. 


AMENTIA 

MENTAL  DEFICIENCY 


AMERICAN. 


AMENTS 

MENTAL  DEFECTIVES 
FEEBLE-MINDED  (oc- 
casionally    used,     but 
now  more  often  applied 
to  Class  4) 


IDIOCY 


IDIOTS 


IMBECILITY 


IMBECILES 


FEEBLE-MINDEDNESS 
MOROSIS 


FEEBLE-MINDED 

MORONS 

The  feeble-minded  under 
the  age  of  sixteen  years 
are  known  as  MEN- 
TALLY DEFECTIVE 
CHILDREN 


MENTAL  DULLNESS 


DULLARDS 
FEEBLY  GIFTED 


MORAL  DEFICIENCY 
MORAL  IMBECILITY 


MORAL  DEFECTIVES 
MORAL  IMBECILES 


FEEBLE-MINDEDNl 
MENTAL  DEFICIEN 
IDIOCY  (occasionally) 


FEEBLE-MINDED 
MENTAL  DEFECTIV, 


IDIOCY 


IDIOTS 


IMBECILITY 


IMBECILES 


(?)  MOROSIS  ! 

FEEBLE  -  MINDEDNl 
(occasionally) 


MORONS 

The     terms     MENTAI 
FEEBLE  and  FEEB 
MINDED  have  now  1 
almost     superseded 
the  term  Morons 


MENTAL  RETARDAi 


MENTALLY  RETARJ 


MORAL  IMBECILITY 
MORAL  DEVIATION 


MORAL  IMBECILES! 
MORAL  DEVIATES 


SYNONYMS 


FRENCH. 

GERMAN. 

TERMS 
SUGGESTED. 

\.RRlfiRATION 
DIOTIE 

SCHWACHSINN 
SCHWACHSINNIGKEIT 
BLODSINN  (Secundarer  Blodsinn- De- 
mentia) 
GEISTESSCHWACHE 

AMENTIA 

\.NORMAUX 

SCHWACHSINNIGE 
BLODSINNIGE 

AMENTS 

DIOTIE 

IDIOTISMUS 
IDIOTIE 

IDIOCY 
IDIOTS 

DIOTS 

IDIOTEN 

MBfiCILLITfi 

IMBEZILLITAT 

IMBECILITY 

MBfiCILES 

IMBEZILLE 

IMBECILES 

)fiBILITfi  MENTALE 
?AIBLESSE  D'ESPRIT 

HALBSCHWACHSINNIGKEIT 
(?)   SCHWACHBEFAHIGKEIT 

MOROSIS 

)fiBILES 

^AIBLES  D'ESPRIT 

(?)  SGHWACHBEFAHIGTE 
GEISTIGMINDERWERTIGE 
LEICHTSCHWACHSINNIGE 
DEBILE 

MORONS 

'ARDIVETfi 

(?)   SCHWACHBEFAHIGKEIT 
SCHWERFALLIGKEIT 

SIMPLICITAS 
vel  STUPIDITAS 
vel  FATUITAS 

rARDIFS 
>UBNORMAUX 

GEISTIGZURUCKGEBLIEBENE 

SCHWACHBEGABTE 

SCHWERFALLIGE 

(?)   SGHWACHBEFAHIGTE 

SIMPLES 
vel  STUPIDS 
vel  FATUOUS 

MBliCILLITfi  MORALE 

SITTLICHE  MINDERWERTIGKEIT 
MORALISCHE  IMBEZILLITAT 
MORALISCHER  SCHWACHSINN 

AMORALIA 

MB^CILES  MORALES 

MORALISCHE  SCHWACHSINNIGE 
MORALISCHE  IMBEZILLE 

AMORALES 

(To  face  f.  464. 

Nomenclature  465 

usual  custom  in  this  country.  In  America  the  term  feeble-minded 
has  not  this  limited  connotation,  but  is  applied  to  the  whole  order 
of  aments,  the  words  mental  deficiency  (and  occasionally  idiocy) 
being  used  as  synonyms.  The  usual  French  generic  terms  are 
I'arrieration  and  I'idiotie  ;  the  usual  German  term  is  Schwachsinn. 

The  mildest  grade  of  amentia  and  the  lowest  degree  of  normal 
intellectual  development  have  been  differentiated  for  some  time  in 
England,  America,  and  France,  and  hence  each  of  these  countries 
possesses  tolerably  well-recognized  terms,  as  shown  in  the  table.  In 
Germany  such  differentiation  does  not  seem  to  be  so  clearly  made, 
and  Schwachbefdhigte  is  often  used  indifferently  of  the  feeble- 
minded and  the  dullards.  This  is  the  case  with  several  of  the  other 
terms  shown  in  the  table,  and  it  is  perhaps  here  that  the  English 
reader  will  experience  the  chief  difficulty  in  knowing  which  particular 
class  is  referred  to.  The  word  moron,  suggested  by  Dr.  H.  Goddard, 
is  now  the  usual  American  designation  for  persons  suffering  from 
the  mildest  grade  of  amentia,  and  thus  corresponds  to  our  feeble- 
minded. So  far  as  I  can  ascertain,  there  is  no  American  term  for 
the  state  of  this  class,  and  I  would  suggest  morosis  (Dr.  Shuttleworth 
suggests  moronity)  as  a  suitable  equivalent.  With  regard  to  the 
lowest  grade  of  normal  intellectual  capacity,  it  is  common  in 
England  to  apply  the  term  the  dull  and  backward  ;  I  think,  how- 
ever, that  it  is  clearly  advisable  to  distinguish  between  mental 
dullness  (which  is  usually  innate)  and  mental  backwardness  (which 
is  often  merely  a  symptom  of  some  removable  cause),  and  the 
innately  dull  seem  to  me  to  be  better  designated  by  the  English 
terms  dullards  or  feebly  gifted,  than  by  the  American  retarded  or 
French  tardifs. 

In  view  of  the  confusion  which  exists  in  the  nomenclature  of 
these  conditions  it  would  obviously  be  a  great  advantage  to  scientific 
research  if  psychiatrists  in  different  countries  could  come  to  some 
common  agreement.  I  have  no  desire  to  add  to  the  babel  which 
already  exists,  and  have  therefore  refrained  from  introducing  any 
new  designations  in  the  preceding  pages  of  this  book.  I  venture  to 
put  forward  certain  terms,  however,  which  might  at  least  form  a 
basis  for  consideration,  and  these  will  be  found  in  column  five  of  the 
table. 


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468 


Primary  and  secondary  dentition  often 

delayed 
Defects    of    prehension,    balance,    and 
progression 

3 
O   en 

•  r!  en 

en  T3 

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en   03 
o3   _, 

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n 

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WQ 

Feeble    circulation  ;     cyanosis  ;     chil- 
blains; subnormal  temperature 
Haemophiha 

Bulimia;  coprophagia 

Late  puberty;  sterility 

Abnormal    presentations  ;    abortions  ; 
sterility 

Irregularities  of  position,  number,  form,  size, 
and  condition 

Gigantism,  dwarfism;  talipes;  deformities  of 
fingers  and  toes;  polydactylism,  syndactyl- 
ism: arms  disproportionately  long;  legs 
short  and  bowed 

Numerous  anomalies 

Moles;   naevi;   supernumerary   mammae;   hair 
arranged  in  multiple  cortices  ;    an  unusual 
development  of  hair  upon  parts  generally 
hairless,   and  an  absence  or  deficiency  on 
those  usually  covered ;  adenoma  sebaceum 

Subnormal  size 
Foetal  malformations 
Various  aberrations 

Numerous  anomalies  of  stomach,  alimentary 
canal,  and  glands 

Lobulated,    horseshoe;    extroversion    of    the 

bladder 
Epi-    and    hypo-spadias;    cryptorchism;    in- 

fantiUsm;  cloacal  opening 
Small  uterus;  fibrous  ovaries;  labial  anomaUes; 

cloacal  opening;  infantilism 

Teeth 
Limbs 

Skeletal  muscles 
Skin 

Heart 
B  oodvessels 

1 

Kidneys  and  bladder 

Male  genitals 

Female  genitals 

(d)   Muscular      and 
cutaneous 

(e)   Circulatory    and 
respiratory 

(/)   Alimentary 

{g)   Urinary  and 
generative 

469 


Page  i 

FORM  FOR  CASE-TAKING. 
Name. 

Address. 

Sex.  Age.  Date  of  Examination. 


47i 


Page  2. 


A.— PREVIOUS  PERSONAL  HISTORY. 


Information  suppUed  by 

Reason  for  seeking  advice. 

When  and  what  was  the  abnormality  first  noticed. 

Physiological  Development  : 

First  tooth.  Walked. 

Clean  in  habits.  Puberty. 


Talked. 


2.  Medical  History  : 

Illnesses.  Accidents. 

Condition  of  mother  during  pregnancy. 
Any  abnormality  at  birth. 


General  state  of  health. 


3.  School  History  : 

Age  when  began. 
Age  at  leaving. 


Kind  of  school. 
Standard  reached. 


Attendance. 


4.  General  Behaviour  and  Disposition  : 


Cheerful. 

Affectionate. 

Destructive. 

Obstinate. 

Truthful. 


Depressed. 

Quarrelsome. 

Mischievous. 

Honest. 

Untruthful. 


Good-tempered.  Bad-tempered. 

Alcohohc.  Cruel. 

Obedient.  Disobedient. 

Dishonest.  Criminal. 

Modest.  Immodest. 


Abilities  : 

Feed  himself.  Wash  and  dress. 

.  Guard  against  ordinary  physical  dangers. 
Do  manual  work.  Go  errands. 

Any  regular  employment.  Any  special  talents  or  tastes. 


B.— FAMILY  HISTORY. 

Brothers  and  Sisters.       Parents,  Uncles  and  Aunts. 


Grandparents. 


M.  .. 

M.B. 
M.S. 


|m.f. 


M.M. 


472 


C— PRESENT  STATE. 

Age.  Date  of  examination. 

General  appearance. 


Page  3 


I.  Physical: 

Height.             Weight.                    Skull.                 ,/^ 

(Size,  shape,  and     /^\ 
abnormalities.)      /     \^ 

/^ 

General  development  and  nutrition. 

'^^^-^ 

/ 

Developmental  Anomalies  and  Stigmata  : 

Face.                  Eyes.                  Ears. 

Nose. 

Mouth. 

Tongue.             Palate.               Teeth. 

Jaws. 

Skin. 

Hands.               Feet.                   Limbs. 

Body. 

Genitals. 

Signs  of  Ill-Health  or  Disease  : 

Heart.  Lungs.  Abdomen.  Glands.  Tonsils. 

Adenoids.  Constitutional  disease — e.g.,  rickets,  anaemia. 

2.  Mental — Sensation  : 

Sight. 

Hearing. 

Tactile. 

Cerebration  : 

Attention. 

Association. 

Memory. 

Reasoning. 

Temperament. 

Emotion. 

Action  : 

Speech. 

Movement  +  or  — . 
Co-ordination. 
Tricks  and  habits. 
Convulsions. 
Reflexes. 

Binet  and  Simon's  Tests  : 

3.  Capabilities — Scholastic  ■ 

Reading. 
Writing. 
Sums. 
Money  values. 

Manual  : 

Special  Aptitudes  : 


473 


474 


IN  DEX 


Abercrombie,  brain  of,  206 
Abnormal  nerve  signs,  123 

in  mentally  defective   chil- 
dren, 163 
Abrin,  effect  of,  upon  fowls,  32 
Abstract  ideas,  115 
Achondroplasia  and  cretinism,  288 
Act,    Defective    and  Epileptic   Chil- 
dren    (Education),     92,     157, 
424 
Idiots,  424,  431 
Inebriates,  444 
Lunacy,  424 
Mental    Deficiency    (1913),    91, 

158,  341.  359 
Provisions    of,    425    et 

seq. 
Action,  123.     See  also  Movements 
Adami,  Professor  J.  G.,  31 
Adenoids  in  Mongolism,  217 
Adenoma  sebaceum,  146,  246 
Esthetic  sense,  122,  314 
After-care  Committees,  statistics  of, 

434 
necessity  for,  455 
Age  of  aments  at  death,  149,  151 
of  feeble-minded  in  workhouses, 

437 
of  parents  as  a  cause  of  amentia, 

52 
Agenesis  corticalis,  87 
Agrammatism,  133 
Alcohol  as  a  cause  of  amentia,  35,  42, 

444 

effect  of,  upon  dogs,  31 
eggs,  31 
guinea-pigs,  31 
human  testes,  31 

susceptibility  of  aments  to,  335, 

444 
Alimentary    system,     anomalies    of, 

147 
AUbutt,  Sir  T.  C,  22     . 
Allegations,   unfounded,   by  aments, 

167.  352 


Alternating  insanity,  351 
Amaurotic  family  idiocy,  272 
Amentia    accompanied    by    porence- 
phaly or  hemiatrophy,  243 
acquired,  21.     Sec  also  Second- 
ary 
and  apes,  28 
and  atavism,  28,  203 
and  epilepsy,  relationship  of,  275 
and  gross  cerebral  lesions,  229 
and  normal  development,  7 
and  paralysis,  230 
causation  of,  20  et  seq.     See  also 

Causation 
classification  of,  89 
clinical  varieties  of,  94,  202,  224 
congenital  and  acquired,  21,  89 
cretinoid,  284 
definition  of,  8 
degrees  of,  90 

delayed  primary,  90,  224,  388     • 
developmental,  90,  224,  232,  388 
diagnosis  of,  380 
due    to    asphyxia    neonatorum, 
229,  236 
birth  injury,  228,  236,  239 
blindness,  297 
cerebral  haemorrhage,  228 

lesions,  225,  242 
deafness,  296,  297 
defective  cerebral  nutrition, 

274,  291 
isolation,  295 
malnutrition,  274,  291 
meningitis,  240,  242 
sense  deprivation,  295 
sunstroke,  240 
toxic  lesions,  226.     Sec  also 

Toxic 
trauma,  228,  238 
eclampsic,  275,  279 
epileptic,  275,  276  et  seq. 
forms  of,  89 
hydrocephalic,  262 
hypertrophic,  251 


475 


476 


Index 


Amentia,  incidence  of,  lo  et  seq.     See 
also  Incidence 

inflammatory,  226 

intrinsic  and  extrinsic,  21 

microcephalic,  202 

Mongolian,  211 

myxoedematous,  284 

nature  of,  i  et  seq. 

pachydermic,  284 

paralytic,  222,  234 

pathology  of,  73  et  seq. 

prevention  of,  462 

primary,  21,  89.  See  also  Primary 

primary     and     secondarj'     con- 
trasted, 224 

prognosis  in,  395  et  seq. 

rachitic,  295 

sclerotic,  247  et  seq. 

secondary,  22,  89,  224.     See  also 
Secondary 

"  sporadic,"  25 

syphilitic,  267 

toxic,  226 

varieties  of,  94,  202,  224 

vascular,  226 

with  moral  deficiency,  320 
paralysis,  222,  234 
porencephaly,  243 
Aments  and  crime,  313  et  seq. 

and  dullards,  8 

and  inferior  races,  29 

and  society,  432 

in  cottages,  442 

in  workhouses,  436,  439 

insane,  342 

location  of,  17 

needing  provision,  441 

number    of,     in     England    and 
Wales,  13,  432 

paralytic,  234 

pauper,  435 

propagation  by,  446,  457 

sane,  342 

sex  of,  17 
American  Breeders'  Association,  41 
Anatomy,  morbid,  82 
Andriezen,  Dr.  L.,  46 
Anomalies,  anatomical,  82,  139 

physiological,  147 
Anthropometric   Committee,    Report 

of.  143 
Anton,  Dr.  G.,  231 
Apes  and  aments,  28 
Aphasia,  motor,  in  amentia,  131 
Aphonia,  132 
Aprosexia,  no 

Aristotle  on  temperaments,  120 
Arithmetic  in  idiots  savants,  307 

teaching  of,  418 
Arndt  and  Sklarek,  84 


Articulation.     See  Speech 
Asexualization,  402,  457 
Ashby,  Dr.  H.,  22,  40,  132,  163,  382 
Asphyxia  neonatorum  as  a  cause  of 

amentia,  26,  57,  229,  236 
Association,  in 
•   in  aments,  112 

development  of,  416 

law  of,  416 

systems,  71,  72,  79,  iii 

tests  for,  364 
Asylums,  aments  in,  18,  343 
Atavism  and  amentia,  8,  28,  203 
Ateleiosis,  204 
Athetosis,  128,  222,  229 

correction  of,  414 
Athyroidea,  282 
Attention,  109 

and  perception,  109 

cultivation  of,  415 

in  aments,  no,  191,  197 

in   mentally   defective   children, 

165 

spontaneous,  109 

tests  for,  363 

voluntary,  no 
Attwood,  Dr.,  48 
Auden,  Dr.  G.  A.,  464 
Audry,  Dr.,  84 
Authorities  under  Mental  Deficiency 

Act,  429 
"  Aztecs,"  the,  210 

Baer,  Dr.,  322 
Baillarger,  203 

line  of,  79,  260 
Barr,  Dr.  M.  W.,  304,  307 
Beach,  Dr.  Fletcher,  23,  47,  156,  205, 
252 

and  Shuttleworth,  Drs.,  40,  43, 

47.  52.56 
Beard,  Dr.  J.,  30 
Becker,  Helene,  case  of,  210 
Beresford,  Dr.,  23 
Bertholet,  Dr.  E.,  31 
Betz'  cells,  72,  231,  232 
Binet  and  Simon's  Tests,  373 
"  Bird  man,"  case  of,  210 
Birth    lesions   causing   amentia,    56, 

228,  236,  239 
premature,  causing  amentia,  26, 

60 
rate,  446,  449 
Births,    number   of,    to   a   marriage, 

446,  448 
Bischoff,  Professor,  210 
Blastophoria,  35 

Blindness,  congenital,  causing  amen- 
tia, 297 
Blood  in  cretins,  283,  287 


Index 


477 


Board  of  Control,  429 
Boaz,  Professor  F.,  32 
Bolton,  Dr.  J.  S.,  34.  72,  78,  139,  277, 

295,  343 
Bond,  Dr.  H.,  23 
Bonfigli,  Dr.,  256,  260 
Bontor,  Dr.  S.  A.,  457 
Bordage's  experiments,  t,2 
Bourdon's  cancellation  tests,  363 
Bourneville,  Dr.,   So,   148,   246,   249, 

^55<  256 
Boyd,  Dr.  R.,  70 
Brain,  atroph}^  of,  87 

bloodvessels  of,  81,  82,  260 
cells,  degeneration  of,  82,  259 
development  of,  71 
in  amentia,  75 
in  dementia,  82 
instability  of,  279 
normal,  71,  72 
pigmentation  of,  76 
consecutive  lesions  of,  85 
cortex,  71,  75 

developmental  anomalies  of,  82 
fibres  of,  71,  72,  78,  79,  260 
gross  lesions  of,  82,  225,  231 
haemorrhage  into,  81,  86,  260 
hemiatrophy  of,  84,  243,  245 
hypertrophy  of,  81 
in  amentia,  75,  82 
in  cretinism,  285 
in  criminals,  77,  322 
in  dementia,  82 
in  microcephaly,  204 
in  Mongolism,  214 
inflammation  of,  86 
malformations  of,  82 
membranes,  of,  87 
morbid  anatomy  of,  82 
regions  of,  affected  in  amentia, 

77.78 
sclerosis  of,  79,  80,  247,  255,  258 
size  of,  and  intelligence,  205 

range   of   normal   variation 
in,  205 
weight  of  normal,  206 
in  aments,  83,  163 
in  criminals,  322 
in  hemiatrophy,  243,  246 
in  hypertrophic  amentia, 252 
in  microcephaly,  205 
in  Mongolism,  214 
Branthwaite,  Dr.,  445 
Bridgman,  Laura,  case  of,  298 
Broca,  Professor,  70 
Brothers  and  sisters  of  aments,  con- 
dition of,  447 
Brunet,  Dr.  D.,  252 
Bunge,  von  Professor,  46 
Burt,  Mr.  C,  367 


Caldecott,  Dr.  C,  40,  151,  21S,  290, 

305,  308,  309,  321,  433 
Cappelletti,  Dr.,  357 
Cardiac  lesions  in  Mongolism,  218 
Cardona,  Professor  F.,  209 
Care,  inadequate,  aments  under,  441 
Carriere,  Dr.,  32 
Case-taking,  376 

form  for,  472 
Caswell,  Oliver,  case  of,  299 
Cataract  in  Mongolism,  216 
Catarrhal    affections    in    Mongolism, 

218 
Catola,  Dr.,  54 

Causation,  factors  of,  acting  after 
birth,  26,  60,  226,  228; 
before  birth,  53,  226,  228; 
during  birth,  26,  56,  228 

abnormalities  of  labour,  56 

age  of  parents,  52 

alcoholism,  42 

cholera,  54 

cocain  poisoning,  30 

consanguinity,  50 

convulsions,  61,  275 

ecbolics,  55 

environment,    2>7>    5i>    224, 
293 

epilepsy,  6x,  275 

exciting  factors,  26 

forceps,  55,  58,  228 

fright,  62,  226 

gross    cerebral    lesions,    73, 
226,  229,  242 

illegitimacy,  55 

injuries,  56,  60 

in  regard  to  local  variations 
of  incidence,  62 

instrumental    delivery,    55, 
58,  228 

intrinsic,  7,2, 

malaria,  54 

malnutrition,  62,  291 

maternal  impressions,  56,  69 

meningitis,  226,  240,  242 

neuropathic  inheritance,  33, 
39 

plumbism,  55 

premature  birth,  36,  60 

primogeniture,  59 

rickets,  62 

shock  and  fright,  62,  226 

slum  life,  38,  160 

sunstroke,  61,  226 

syphilis,  47,  267 

teething  convulsions,  61 

toxic,  00,  226 

tuberculosis,  47 

typhoid,  54 

typhus,  54 


478  Index 

Causation,     factors     of,     whooping- 
cough,  229 

of  primary  amentia,  21 

of  secondary  amentia,   37,   226, 
228,  229 
Cells  of  brain.     See  Brain 
Cerebellum,  atrophy  of,  259 

in  microcephaly,  204 

in  Mongolism,  214 

lesions  of,  in  amentia,  85 
Cerebration,  108 
Cerretti,  the  brothers,  210 
Chance,  Sir  W.,  434 
Charitable    institutions,    aments    in, 


Charts  of  family  histories,  65-69 
Children    born    during    insanity    of 
mother,  55 

dull  and  backward,  3 S3 

dull  owing  to  disease,  385 

epileptic,  387 

feeble-minded,  156  et  seq. 

grades  of  normal,  383 

innately  dull,  383 

insane,  387 

mentally  defective,  156 

of  delayed  mental  development, 
382 
Choking,   liability  of  idiots  to,    197, 

4"3 
Chorea  in  aments,  222 
Choreiform  movements,  229,  235 
Circulation  in  aments,  147 

in  Mongolism,  217 
Civil  incapacity  of  aments,  341 
Classification  of  amentia,  89  et  seq. 

table  of,  97 
Clinical  varieties  of  primary  amen- 
tia, 202 
of  secondary  amentia,  224 
Clothing  of  aments,  403 
Clouston,  Sir  T.  S.,  34,  141,  142 
Colour-blindness  in  aments,  104 

discrimination,     cultivation     of, 
410 
Combemale,  Dr.,  31 
Commission,  Lunacy,  149 

of  Legislature  of  Connecticut,  40 
Royal,   on  care  and   control  of 
feeble-minded    (of    1904),    10, 
22,  27,  91.  158.  324.  424.  432, 
433,  441,  451 
Royal,    of   Sardinia   on   cretins, 
283 
Committee,  Anthropometric,  143,  322 
Departmental,  of  Board  of  Edu- 
cation, 157 
for   care   of  mentally  defective, 
430 
Common  sense,  lack  of,  in  aments,  188 


Compensation   of   neurones   in   cere- 
bral lesions,  231 
Complications    of   primary   amentia, 

220 
Conduct,  psychological  basis  of,  314 
regulation  of,  6 

disorder  of,  and  intelligence,  321 
and  moral  sense,  314 
and  morbid  impulse,  318 
and  will,  317,  338 
Consanguinity  as  a  cause  of  amentia, 

50 
Consonantal  defects  in  aments,   132. 

See  also  Speech 
Contemporaries  of  aments,  447-448 
Contractures  in  paralytic  aments,  235 

in  sclerotic  aments,  248,  249 
Control,    defect  of,   in   aments,    127, 
166,  318,  340 
influencing       responsi- 
bility, 338,  340 
inadequate,  441 
Convictions,  number  of,  443 
Convulsions  (see  also  Epilepsy)  as  a 
cause  of  amentia,  61,  230 
as  a  cause  of  death,  153 
infantile,  279 

in  amaurotic  family  idiocy,  274 
in     amentia     due     to     cerebral 

lesions,  227,  229,  230 
in  epileptic  amentia,  278 
in  feeble-minded,  imbeciles  and 

idiots,  221 
in  hydrocephalus,  263 
in   mentally   defective   children, 

172 
in  microcephalics,  209 
in  Mongolism,  221 
in  paralytic  aments,  235 
in  porencephaly,  244 
in  primary  amentia,  221 
in   sclerotic   amentia,    248,    252, 

257,  261 
in  syphilitic  amentia,  268 
in  toxic  amentia,  227 
Jacksonian,  229,  235 
predisposition  to,  279 
Co-ordination,  defects  of,  127 

development  of,  413 
Coprolalia,  133 

Corpus  callosum,  anomalies  of,  74 
Cottages,  aments  in,  442 
Cotton,  Dr.  H.  A.,  41 
Couchard,  Dr.,  211 
Craniectomy  in  amentia,  401 
Cranium,  anomalies  of,  in  aments,  87, 

139.  141 
in  cretins,  283 
in  criminals,  322 
artificial  compression  of,  58 


Index 


479 


Cranium,  bosses  of,  141 
circumference  of,  140 
in  hydrocephalus,  263 
in  hypertrophic  aments,  252 
in  microcephahcs,  207 
in  Mongohsra,  215 
in  rickets,  264 
mensuration  of,  139 
oxycephalic,  141 
premature  synostosis  in   micro- 
cephaly, 203 
scaphocephalic,  141 
spherical,  141 
"  sugar-loaf,"  141 
Cretinism,  282  et  seq. 

and  Mongolism,  220 
endemic,  282 

causation  of,  282 
description  of,  283 
sporadic,  284 

causation  of,  284 
description  of,  285 
differential  diagnosis  in,  287 
pathology  of,  285 
prognosis,  288,  399 
treatment  and  its  result,  288 
Cretinoid  idiocy,  212,  284 
Crichton-Browne,  Sir  J.,  23,  54,  55 
Crimes,  nature  of,  444 
Criminal  aments,  187,  313  et  seq. 

illustrative  cases  of,  328  et 

seq. 
number  of,  324 
types  of,  326 
responsibility,  337 
Criminals,   habitual,  antecedents  of, 

323 
brain  of,  77,  332 
causation  of,  34,  320 
mental    characteristics     of, 

322 
physical   characteristics  of, 

potential,  317 

relation  of,  to  aments,  321 
Crocker,  Dr.,  146,  250 
Crothers,  Dr.,  46 
Crowley,  Dr.  R.,  161 
Cruelty  of  feeble-minded  children,  167 

of  idiots,  199 

of  moral  defectives,  321,  326 
Crzillitzer,  Dr.,  59 
Cunning  of  aments,  167,  327,  328 
Cunningham  and  Telford-Smith,  Drs., 

211 
Curability  of  amentia,  161,  395 
Cutaneous  sensation,  105,  412 

system,  anomalies  of,  106 

tests  for,  363 
Cuvier,  brain  of,  206 


449 


Dahl,  Dr.  Ludvvig,  40 

Dalton,  Dr.,  210 

Danielson,  Miss  F.  H., 

Dareste,  Dr.,  54 

Darwin,  C,  133 

Darwin,  G.,  51 

Daumer,  Professor,  300 

Davenport,   Dr.   C.    B.,   28,   36,   449, 

450 
Dawson,  Dr.  W.  R.,  444 
Deaf-mutism  in  primary  amentia,  223 
Deafness  in  aments,  105,  145,  228 

causing  amentia,  296,  297,  308 
Dean,  Dr.,  48 

Death,  age  at,  in  amentia,  149,  151 
in  Mongolism,  218 

causes  of,  in  amentia,  153,  154 
Dehnition  of  amentia,  8 

of  feeble-mindedness,  91 

of  idiocy,  94 

of  imbecility,  93,  1S9 

of   mentally   defective   children 
92 

of  moral  imbecility,  94 

of  "  normal  "  mind,  4 
Degeneracy,  mode  of  production,  33 

stigmata     of,      137.      See     also 
Stigmata 
Degeneration  of  brain  cells,  82,  259, 

269 
Degrees  of  amentia,  90 

prognosis  in,  399 
Delisle,  Dr..  58 
Delivery,    instrumental,    as   a   cause 

of  amentia,  55,  58,  228 
Delusional  insanity,  352 
Delusions  in  aments,  346,  349,  352 

influencing  responsibility,'  340 
Dementia,  condition  of  brain  in    8^ 
87  '     ■' 

distinguished   from   amentia,    r, 
9,  393 

in  aments,  358 

in  epilepsy,  277 

in  hydrocephalus,  264 

in  insanity,  352,  358 

in  primary  amentia,  358 

in  syphilitic  amentia,  268 

prcccox,  3  58 

diagnosis  from  amentia,  39^ 
Dendy,  Miss  M.,  446 
Dentition  in  aments,  time  of,  148 

in  cretins,  286 
De  Sanctis'  tests.  376 
Destructiveness  in  idiots,  198 
Detention,  procedure  in,  426 
Developmental  anomalies  in  aments 
139 
in  criminals,  -^zz 

data,  normal,  466 


480 


Index 


Developmental   or   delayed   primary 

amentia,  90,  224,  232,  388 
Development,  delayed,  293 
of  mind,  3,  loi,  274,  404 
of  moral  sense,  315 
of  religious  sense,  315 
retarded,  382,  388 
De  Vries,  Professor  H.,  29 
Diagnosis  of  amentia,  380 

during    adolescence    and    adult 
life,  391  [ 

infancy  and  childhood,  380 
school  age,  382  j 

from  dementia,  393 

general  paralysis,  393 
insanity,  392 
of    mentally    defective    children    ^ 
from  imbeciles,  390  | 

Dietary  in  amentia,  403  ' 

Disposition  in  aments,  121,  167,  175, 

176,  185,  192,  198,  452  j 

Dobson,  Dr.  M.  B.,  261 
Donaldson,  Dr.  H.  H.,  298 
Douglas,  Dr.,  434 

Down,   Dr.   J.  Langdon,  44,  47,  48, 
52,   141,   142,   149,   204,   211,   215, 
234.  306,  307,  396 
Down,  Dr.  R.  Langdon,  216,  218,  256, 

303.  305,  464 
Drawing,     capacity     for,     in     idiots 

savants,  303 
Drugs  in  amentia,  400 
Dugdale,  R.  L.,  324 
Dullards,  2,  465 

compared  with  aments,  8,  384 
Dull  and  backward  children,  382 
Dullness,  mental,  acquired,  385 

innate,  383 
Duncan,  Dr.  Matthews,  52 
Dunces,  384 
Dwarfs  and  microcephalics,  204 

Ear,  anomalies  of,  in  aments,  144 
in  criminals,  144 
in  insane,  144 
and  hearing,  105 
disease  of,  105 
Earlswood    Asylum,    particulars    re- 
garding mortality  in,  151 
et  seq. 
the  Genius  of,  307 
Earnings   of   feeble-minded   persons, 

435 
Ebbinghaus,  Professor,  368 
Ecbolics  as  a  cause  of  amentia,  55 
Echolaha,  134 
Eclampsia  and  epilepsy,  275 
"  Eclampsic  "  amentia,  279 
Edinger,  Professor,  262 
Educability  of  aments,  407  - 1 


Education    Act    regarding    defective 
and  epileptic  children,  92,  157, 
424 
authority,  duties  of,  430 
of    aments,    general    principles, 
403 .     See  also  Training 
Ego,  perversion  of  the,  342 
Eichholz,  Dr.  A.,  23,  161 
Eichler,  Professor,  75 
Ellis,  Dr.  Havelock,  322 
Embolism  causing  amentia,  228 
Emotion,  121 

in  feeble-minded  persons,  185 

in  idiots,  198 

in   mentally   defective   children, 

166 
in  primary  aments,  122 
in  secondary  aments,  234 
tests  for,  367 
Employment   of   feeble-minded   per- 
sons, 177,  184,  433 
in  workhouses,  43  7 
Encephalitis  causing  amentia,  226 

pathology  of,  86 
Enteric  causing  amentia,  54 
Enuresis,  treatment  of,  402 
Environment  and  heredity,  relative 
imiportance  of,  22,  25,  320 
and  maintenance  of  existence,  4 
and  mentally  defective  children, 

160 
and  moral  defect,  319 
as  a  cause  of  germ  variation,  29, 

30,  462 
factors  of,  causing  amentia,  37, 
^T).     See  also  Causation 
Epicanthus,  145 
Epilepsy.     See  also  Convulsions 

and    amentia,     relationship    of, 

275 
and  eclampsia,  275,  279 
as  a  cause  of  amentia,  61,  275 
as  a  cause  of  death,  153 
as  a  cause  of  dementia,  277 
as  a  cause  of  dullness,  3S7 
in  children,  3S7 
in  feeble-minded  persons,  221 
in  gross  cerebral  lesions,  221,  227, 

228,  230,  233,  235 
in  idiots,  197,  221 
in  imbeciles,  191,  221 
in  microcephalics,  209 
in  paralytic  aments,  235 
in  primary  amentia,  221 
neuropathic  inheritance  in,  34 
psychic,  334,  421 
relations  of,  to  amentia,  275 
Epileptic  amentia,  description  of,  276 
illustrative  cases  of,  280 
prognosis  in,  278,  398 


Index 


481 


Epileptic  insanity,  352 

"  Epiloia,"  256 

Esquirol,  Dr.,  90,  130 

Establishments,  varieties  of,  429 

Ethnic  types  of  amentia,  95 

Eugenics,  462 

Examination    of    mental    defectives, 
359,  377 

Excitement  in  aments.     See  Disposi- 
tion and  Emotion 

Existence,  maintenance  of,  in  aments, 
6 
in  animals,  3 
in  man,  4 

Explosive  type  of  moral  defectives, 
334.  421 

Eye,    anomalies    of,    145.     See    also 
Vision 

Eyes  in  Mongolism,  216 

"  Facile  "  aments,  421 

Facile  type  of  moral  defect,  331 

Facility,  tests  for,  366 

Factors    of   causation    in   regard    to 

local  variations  of  incidence,  62 
Fagge,  Dr.  Hilton,  284 
Fairholme,  Mr.  E.  G.,  304 
Family  history  charts,  65-69 
Fantasy,  114 

Farr  and  Newsholme,  Drs.,  448 
Fatty  tumours  in  cretinism,  286 
Fecundity  of  neuropaths,  446 
Feeble-minded  adults,  173  et  seq. 

character  of,  175 

description  of,  174 

employment    of,    177,    433, 

437 

illustrative  cases  of,   177  et 
seq. 

incapacity  of ,  184 

in  charitable  institutions,  iS 

in  lunatic  asylums,  18,  343, 
438 

in    Poor    Law    institutions, 
18,  436,  451 

location  of,  17 

number  of,  173 

of  stable  mental  equilibrium, 
176 

of    unstable    mental  equili- 
brium, 185 

receiving  parish  relief,  438 

sex  of,  174 
children,  156  et  seq. 

abnormal  nerve  signs  in,  163 

and  slum  life,  160 

clinical  varieties  of,  171 

"  cured,"  161 

definition  of,  92,  157 

description  of,  162 


Feeble-minded  children,  gradesof,  167 
incidence  of,  158,  160 
in  special  schools,  168 
mental  condition  of,  164 
number    in     England     and 

Wales,  159 
physical  condition  of,   162 
scholastic  acquirements 

compared   with   ordinary 
children,  168 
sex  of,  162 
social  status  of,  162 
stigmata  of  degeneracy  in, 
162 
criminals,  313 
insane,  342 
persons,  173 
vagrants,  440 
Feeble-mindedness,  definitions  of,  91, 

173 
grades  of,  92 
Fennell,  Dr.  C.  H.,  215 
Fenwick,  Dr.  Soltau,  290 
Fere,  Dr.,  31 

Fingers  in  Mongolism,  217 
Firth,  Dr.  A.  C.  D.,  403 
Flechsig,  association  centres  of,  71 
Forbes,  Dr.  D.,  383 
Forceps,  use  of,  as  a  cause  of  amentia, 

55.  58,  228 
Forel,  Professor,  35 
Fournier,  Dr.  E.,  49 
Fowler  and  Dickson,  Drs.,  256,  261 
Eraser,  Dr.  Alec,  243 
"  Freddy,"  the  case  of,  210 
Fright,  as  a  cause  of  amentia,  62 

determining  insanity,  345 
Freud,  Dr.  S.,  74,  81,  86,  230 
Fundus    oculi    in    amaurotic    family 

idiocy,  273 

Galton,  F.,  44,  113,  461 
Gambetta,  brain  of,  206 
Games,  use  of,  in  training,  414 
Garrod,  Dr.  A.  E.,  218 
General    paralysis,     diagnosis    from 
amentia,  393 

in  aments,  354 

in  syphilitic  amentia,  268 
Generative  organs,  anomalies  of,  147 
"  Genetous  "  variety,  95 
Genius,   the,   of  Earlswood   Asylum, 

307 
Germ  plasm  and  environment,  29 
continuity  of,  29 
nature  of  defect,  23 
origin  of  defect,  27 
transmission  of  deitect,  35 
variations  of,  27,  30,  31,  32 
factors  causing,  39,  462 

31 


482 


Index 


Gestation,    importance    of    mother's 

condition  during,  26,  53,  55,  213 
Gheorghiu,  Dr.,  31 
Giacomini,  Professor,  203 
Gilford,  Dr.  Hastings,  204 
Gill,  Dr.,  445,  452 
Gillet,  Dr.,  52 
Gliosis.     See  Sclerosis 
Guttony  in  idiots,  197 
Goddard,  Dr.  H.  H.,  40,  41,  92,  143, 

373.  376,  383.  450,  465 
Goitre  in  endemic  cretins,  282 

in  sporadic  cretins,  284 
"  Goose  man,"  the,  210 
Gordon,  Dr.,  48,  213,  257,  274 
Goring,  Dr.,  59 

Gowers,  Sir  W.  R.,  34,  62,  228,  277 
Gradenigo,  Dr.,  144 
Grandoni,  Antonia,  209 
Gray,  Dr.,  328 
Grenier,  Dr.,  455 
Grenzer,  Dr.,  142 
Gruhle,  H.  W.,  320,  323 
Guardianship,  428 

Habits  and  tricks,  126 
Habitual  criminals,  326 
Haemorrhage,  cerebral,  81,  86,  228,260 
Hair,  growth  of,  in  aments,  146,  207 
Hallucinations  in  aments,   346,   349, 

350 
Halonen,  Agnes,  case  of,  299 
Hammarberg,  Dr.,  75 
Hands,  deformities  of,  143 

in  Mongols,  217 
Hansen,  Dr.  S.,  59 
Hartog,  Professor  M.,  30 
Hauser,  Kaspar,  the  case  of,  300 
Head-nodding,  126,  257,  261 
Hearing,  104 

cultivation  of,  412 

in  amaurotic  family  idiocy,  274 

in  cretins,  283 

in  hydrocephalus,  263 

in  idiots  savants,  303 

in  new-born  child,  104 

tests  for,  363 
Heart,  anomalies  of,  146 

in  Mongolism,  218 
Heart,  tumours  of,  in  sclerotic  amen- 
tia, 256,  261 
Helin,  Dr.  Aug.,  299 
Heller,  Dr.,  54 

Hemiatrophy  of  brain,  84,  243,  245 
Heredity,  24 

and    environment,    relative   im- 
portance of,  22 

neuropathic,  33 
in  aments,  39 
in  cretins.  284 


Heredity,  neuropathic,  in  criminals, 

323 
in  microcephaly,  203 
in  Mongolism,  213 
in  syphilitic  amentia,  50 
Heron,  Dr.  D.,  59 
Heubner,  Dr.  O.,  250 
"  Hill  folk,"  the,  449 
Hirsch,  Dr.,  269,  272 
Histology  of  primary  amentia,  75 

of  secondary  amentia,  82 
History,  family,  378,  388 

previous  personal,  377,  387 
Hjorth,  Dr.  B.,  213 
Hoffman,  G.  von,  459 
Holmes,  Dr.  A.,  360,  361,  367 
Holt,  Dr.  E.,  86 
Home  Secretary,  the,  324,  428 
Home  training  of  aments,  408 
Homes,  rescue,  statistics  of,  45  r 
Horsley,  Sir  Victor,  401 

and  Sturge,  46 
Houze,  204 

Howe,  Dr.,  43,  298,  307 
Hunger,  sensation  of,  107 
Huschke,  Dr.,  214 
Hutchison,  Dr.  R.,  23,  289,  290 
Huth,  A.,  50 
Huxley,  Professor,  27 
Hybernation  of  aments,  149 
Hydrocephalic   amentia,    description. 
of,  262 
and  cretinism,  288 
and  hypertrophy,  252 
illustrative  cases  of,  264 
Hydrocephalus,  acute,  263 
arrested,  262 
cause  of,  85,  262 
in  microcephalics,  86 
in  primary  amentia,  222 
pathology  of,  85 
Hypertrophic  sclerosis,  251 
and  cretinism,  288 
Hypertrophy  of  brain,  251 

and  hydrocephalus,  252 
pathology  of,  81 

Ideation,  114 

in  aments,    114,    175,    177,    197^ 
201 
Idiocy,  195 

absolute,  complete  or  profound.., 
200 

amaurotic  family,  272 

apathetic  and  excitable,  198 

by  sense  deprivation,  295 

"  cretinoid,"  212 

definition  of,  94,  195 

description  of,  196 

epilepsy  in,  221 


Index 


483 


Idiocy,  illustrative  cases  of,  199 

maniacal  excitement  in,  199 

mental  and   nervous  character- 
istics of,  197 

partial  or  incomplete,  196 

physical  characteristics  of,  196 
Idioglossia,  133 

Idiots,   number  of,   in   England  and 
Wales,  15,  195 

receiving  Poor-Law  relief,  439 

savants,  302  et  seq. 

sex  of,  196 
Illegitimacy,  451 

as  a  cause  of  amentia,  55 
Ill-health    of    mother    during    preg- 
nancy, 26,  53,  213 
Imagination,  114 

in   mentally   defective   children, 
166 
Imbeciles,    and    mentally    defective 
children,  390 

epilepsy  in,  221 

insane,  344 

in  schools,  439 

number    of,     in     England     and 
Wales,  189 

receiving  Poor-Law  relief,  439 

sex  of,  190 
Imbecility,  189 

definition  of,  93,  189 

description  of,  190 

diagnosis  of,  390 

grades  of,  93 

illustrative  cases  of,  192 

mental   and   nervous  character- 
istics of,  191 

physical  characteristics  of,  190 
Imitation  in  aments,  114,  208,  219 
Improvement  in  amentia,  396 
Impulses,  morbid,  318 
Inbreeding,  effects  of,  50 
Incapacity,  civil,  of  aments,  341 

of   feeble-minded    persons,    184, 

453 
Incidence  of  amentia,  10  et  seq. 
in  United  Kingdom,  13 
in    urban    and    rural     dis- 
tricts, 64 
relative  to  insanitj^  14,  17, 
63  ;  to  sex,  17 
of  insanity,  14 
of  mentally  defective  children  in 

schools,  159 
of  moral  defectives,  325 
of     the     respective    degrees    of 
amentia,  15,  64 
Inco-ordination,  127 

correction  of,  413,  414 
Industrial  training,  419 
Inebriate  reformatories,  aments  in,  445 


Inebriety,  444 

Infantile  cerebral  degeneration,  272 
Inflammation  of  brain,  86 
Inflammatory  amentia.     See  Toxic 
Inheritance   and   environment,    rela- 
tive influence  of,  22 
Injuries.      See  Trauma 
Insanity,  alternating,  351 

and  amentia,  9,  342,  387 

and  crime,  337 

and  dementia,  9 

and  town  life,  63 

antecedent,  as  a  cause  of  amen- 
tia, 39 

causation  of,  342 

clinical  varieties  of,   in  aments, 

345 
"  congenital,"  342 
delusional,  352 

determining  causes  of,  344,  345 
epileptic,  352 
in  children,  387 
incidence  of,  relative  to  amentia, 

14,  17,  63 
in  feeble-minded,  345 
in  idiots  and  imbeciles,  344 
in  mother,  effect  upon  children, 

55 
moral,  313 

neuropathic  inheritance  in,  34 
predisposition  to,  in  aments,  342, 

343 
recurrences  in,  351 
Institutions,  aments  in,  17,  439,  442 
Intellectual  defect  and  moral  defect, 

relationship  between,  320 
Intellectual  sense,  122 
Intelligence,  4,  116 

and  size  of  brain,  205 
tests  for,  368 
training  of,  415 
Interest,  arousal  of,  405 

importance  of,  in  training,  414, 
415 
Ireland,  Dr.  W.  W.,  45,  95,  128,  142, 

208,  211,  245,  252,  263 
Isolation  amentia,  295 

illustrative  cases  of,  297 
prognosis  in,  399 
Itard's  wild  boy,  105 

Jaws,  anomalies  of,  143 
Jendrassik,  81 

Jews  and   amaurotic   family   idiocy, 
272 
and  intermarrying,  51 
"  Joe,"  the  case  of,  208,  211 
Johnson,  Samuel,  58,  318 
Johnstone,  Dr.,  447 
Joints  in  Mongolism,  217 


484 


Index 


Judgment,  115 

tests  for,  367 
Judicial  authority,  426 
Juke,  family,  the,  323 
Julius  Caesar,  277 

Kaes,  Professor,  72,  78,  322 

Kallikak  family,  the,  450 

Kalmuc  variety  of  amentia,  211 

Keen,  Dr.,  401 

Keller,  Helen,  case  of,  299 

Kellner,  Dr.,  48 

KerUn,  Dr.,  43,  47,  52 

Kerr,  Dr.  J.,  23 

Kidneys   in   sclerotic   amentia,    256, 

257,  260 
Kiernan,  Dr.,  447 
Kind,  Dr.,  43 
Kindergarten  occupations  in  training, 

405 
Kingdon  and  Russell,  Drs.,  272,  273 
Kleptomania,  340 
Klob,  Dr.,  75 
Knowledge,   defective,   and    criminal 

responsibility,  339 
Koch,  Dr.  J.L.  A.,  40 
Kolk,  Schroeder  van  der,  74,  323 
Korosi,  Dr.,  52 
Krober,  Dr.,  48 
Kundrat,  Professor,  84,  244 

Labour,  abnormalities  of,  as  a  cause 

of  amentia,  56 
"  Lalling,"  132,  382 
Lamination,  cortical,  in  amentia,  77 

in  sclerosis,  259 

normal,  71 
Language  and  reasoning,  116 
Lankester,  Sir  E.  R.,  23 
Lankester,  Dr.,  55 
Lannelongue,  Dr.,  401 
La  Page,  Dr.,  40,  132,  139,  141,  162 
Larger,  Drs.  R.  and  H.,  148 
Lattes,  Dr.,  322 
Law  of  England  concerning  aments, 

424 
Lead-poisoning  causing  amentia,  55 
Legal  responsibility  of  aments,  337 
Lesions,  cerebral,  and  amentia,  225, 
229-233 
initial      symptoms     of, 

226,  229 
nature  of,  235 
prognosis  in,  231 
situation  and  extent  of, 

232 
varying  effects  of,  23 
consecutive,  of  encephalon,  85 
of  motor  cortex,  effect  of,  232 
Lethal  chamber,  455 


Lewis,  Dr.  Bevan,  23,  75,  76,  77 

Lips,  anomalies  of,  146 

Little,  Dr.,  57 

Little's  disease,  58,  86,  228 

Littleton  House  School,  170 

Lize,  Dr.,  30 

"  Lobster  "  hand,  143 

Local  Authority,  430 

Location  of  aments,  17,  439 

needing  provision,  442 
Lock  wards,  aments  in,  452 
Locke,  Mr.,  434 
Logical  sense,  definition  of,  314 

in  aments,  122 
Lombroso,  Professor,  208,  210,  322 
Looft,  Dr.  Karl,  43 
Lucon,  Dr.,  44 
Lunatics.     See  Insanity 
Lustig,  Dr.,  32 

Macrocephaly,  140,  223 
Maier,  Dr.,  321 

Malnutrition  as  a  cause  of  amentia, 
62,  291 

intra-uterine,  292 

extra-uterine,  292 
Mania  in  aments,  346 
Marie,  Dr.,  81 
Marriage,  restriction  of,  458 
Marro,  Dr.,  52,  323 
Masturbation  in  aments,  192 
Maternal  impressions,  56,  69 
Maternity  wards,  aments  in,  451 
Maudsley,  Dr.  H.,  iii,  306,  313,  323 
McCarrison,  r^lajor  R.,  282 
McDowall,  Dr.  T.  W.,  207 
Mcintosh  and  Fildes,  Drs.,  49 
Melancholia  in  aments,  349 
Melland,  Dr.,  437,  451 
Membranes  of  brain,  condition  of,  87 
Memory,  112 

cultivation  of,  416 

in  aments,  113 

in  idiots  savants,  304 

in   mentally   defective   children, 

165 
tests  for,  365 
Mendelism,  24,  25,  35 
Meningitis  causing  amentia,  226,  240, 
242 
pathology  of,  86 
Menstruation  in  aments,  148 
Mental  characteristics  of  aments,  99 
et  seq. 
deficiency,  literal  meaning  of,  i 
Mental  Deficiency  Act  (1913),  425 
Mental  retardation,  293,  382,  385 

tests.     See  Tests 
Mentally     defective     children,     156. 
See  also  Feeble-minded  children 


Index 


485 


Mercier,  Dr.  C,  23,  328,  339,  341,  342 

Meystre,  case  of,  299 

Microcephalic  amentia,  202 
and  atavism,  203 
and  cranial  synostosis,  203 
and  dwarfs,  204 
brain  in,  204 
causation  of,  202 
definition  of,  202 
description  of,  207 
illustrative  cases  of,  209 
intelligence  in,  208 
mental  condition,  208 
morbid  heredity  in,  203 
pathology  of,  204 
physical  condition,  207 
prognosis  in,  397 

Microgyria,  84 

Microkinesis,  123 

Mill,  J.  Stuart,  422 

Mimicry  in  microcephalics,  208 
in  Mongols,  219 

Mind,  developmental  potentiahty  of, 

3.  7 
disease  of,  8 
essential  purpose  of,  3 
ideal,  2 
nature  of,  99 
normal,  4 

development  of,  3,  loi,  274, 

404 
range  of,  i 
types  of,  314 
relation  of,  to  brain,  99 
Mind,  Gottfried,  case  of,  304 
Mingazzini,  Professor,  211 
Mirror-writing,  135 
Modification,  somatic,  39 
Mohammed,  277 
Mongolian  amentia,  211 

amelioration  of  bodily  signs 

in,  218 
and  cretinism,  220 
and  syphilis,  212,  213 
causation  of,  212 
description  of,  215 
grades  of,  219 
mental  and  nervous  charac- 
teristics of,  218 
pathology  of,  214 
physical   characteristics    of, 

215 
prevalence  of,  212 
prognosis  in,  397 
semi-,  211 
Moon,  Dr.  R.  O.,  279 
Moral  deficiency,  313  et  seq. 

and    amentia,     relationship 

between,  320 
description  of,  325 


Moral  deficiency,  diagnosis  of,  394 

illustrative  cases  of,   328  et 

seq. 
incidence  of,  324 
types  of,  explosive,  324 
facile,  331 

habitual  criminal,  326 
imbecility,  94,  313 
insanity,  313 
sense,  122,  166,  314,  421 
development  of,  315 
training,  420 
Morel,  Dr.,  34 
Morons,  92,  465 
Morosis,  465 
Mortality  of  aments,  149-155,  448 

causes  of,  153,  154 
Motor  aphasia  with  amentia,  241 
cortex,  lesions  of,  232 
functions  in  aments,  123 

cultivation  of,  407,  412 
in  idiots  savants,  303 
Mott,  Dr.  F.  W.,  23 
Movement,  123 

Movements,  anomalies  of,  124,  128 
automatic,  126,  199 
co-ordinated,  124 
deficient,  125 
deliberate,  124,  127 
development  of,  407,  413 
excessive,  125 
imitation,  128 
impulsive,  124,  127 
inco-ordinated,  127 
instinctive,  124 
irregular,  126,  127 
reflex,  124 
spontaneous,  123 
tests  for,  371 
training  of,  407,  412 
transfer,  128 
volitional,  124 
Miiller,  Professor  Max,  133 
Mumbray,  Miss  N.,  168,  412 
Murray,  Dr.  G.  R.,  289 
Muscle  sense,  106 

cultivation  of,  411 
Muscles,  anomalies  of,  146 

sensations  from,  106 
Music,  fondness  for,  in  idiots  savants, 
306 
in  Mongols,  219 
value  of,  in  training,  412,  417 
Mutilations,  transmission  of,  29 
Myers,  Dr.  C.  S.,  361,  362 
Myxcedema  and  cretinism,  285 

Nacke,  Dr.  P.,  45 
Nam  family,  the,  450 
Napoleon,  206,  277 


X 


486 


Index 


National     Association     for     Feeble- 
minded, 434 
National  Vigilance  Society,  451 
Nerve  ceUs.     See  Brain,  ceUs  of 
Nerve  fibres.     See  Brain,  fibres  of 

signs,  abnormal,  123,  163 
Nettleship,  Dr.,  36 
Neurasthenia  in  children,  387 
Neuroblasts  in  amentia,  76 

in  normal  brain,  71 
Neuroglia,  condition  of,  79 

contraction  of,  80,  248,  255 
Neuropathic  diathesis,  25,  33,  39,  213 

antedating  of,  34 

in  amentia,  34,  39 

in  cretins,  284 

in  criminals,  323 

in  epilepsy,  34 

in  insanity,  34 

in  sclerosis,  257 

mode  of  transmission  of,  36, 

37 
ongm  of,  33 
heredity.     See  Heredity 
Neuro-physiology  of  amentia,  99 
Newman,  Sir  G.,  434 
Newsholme  and  Farr,  Drs.,  448 
Neyroz,  Dr.,  440 
Nicholson,  Dr.,  323 
Nobihng-JoUy,  74 
Nomenclature,  464 
Norman,  Dr.  ConoUy,  243 
Norsworthy,  Miss  X.,  112,  113 
Nose,  anomahes  of,  145 
Number  of  aments  in  England  and 
Wales,  13,  432 
inadequately  cared  for, 
441 
of  insane,  432 
of  moral  defectives,  325 
Nutritional  amentia,  291 
Nystagmus,  128 

Object-lessons,  value  of,  in  training, 
416 

Obstetrical  stigmata,  148 

Occupation  of  aments.     See  Employ- 
ment 

Occupations  suitable  for  aments,  420 

Offences  committed  by  aments,  444 

Ofl'spring  of  aments,  451 

of  neuropathies,  55,  447 

Operative  treatment  of  amentia,  401 

Oppenheim,  Professor,  226 

Optic   atrophy  in   amaurotic   family 
idiocy,  273 
in  hydrocephalus,  263 

Organic  sensations  in  aments,  107 

Ormond,  Dr.  A.  W.,  216 

Orr  and  Rosanoff,  37 


Osseous  system,  anomalies  of,  139 

Otorrhoea  in  aments,  105 

Outdoor  reUef,  aments  in  receipt  of, 

18,  435 
Owen,  Professor,  210 
Owen,  Dr.  S.  A.,  267 
Oxycephahc  skuU,  141 

Pachydermic  idiocy,  284 
Pain,  appreciation  of,  106,  327 
Palate,  anomalies  of,  141 

causation  of,  142 

cleft,  142 

saddle-shaped,  142 
V-shaped,  142 
Palpebral  fissures  in  Mongols,  215 
Paracentesis  in  hydrocephalus,  401 
Paralysis  and  amentia,  230,  234 

general.     See  General  paralysis 

in     amentia     due     to     cerebral 
lesions,  229,  230,  234 

in  hydrocephalus,  263,  265,  266 

in  idiocy,  196 

in  microcephahcs,  209 

in  porencephaly,  244 

in  primary  amentia,  222 

in  sclerosis,  248 

in  toxic  amentia,  227 
"  Paralytic  "  aments,  234 
Parasyphihtic  conditions,  49 
Parents,  age  of,  as  a  cause  of  amentia, 

52 
Parkinson,  Mr.  R.,  171 
Parry,  Dr.,  452 
Parturition,  anomahes  of,  57 
Pathologj^  of  amentia,  73  et  seq. 
Paul,  Dr.  C,  30 
Pauperism  in  aments,  435 
Pearce,  Dr.  F.  H.,  151,  215 
Pearse,  Dr.,  452 
Pearson,  Professor  K.,  59 
Perception,  loS 
Perkins,  Mr.  H.  W.,  226 
Perseveration,  112,  365 
Peruvians,  ancient,  206 
Peter  the  Great,  277 
Petersen,  Dr.  F.,  102,  105,  141,  272, 

302 
Phthisis.     See  Tuberculosis 
Physical  characteristics  of  amentia, 

137 et  seq. 
Physicians,  Royal  College  of,  173 
Physiological  anomahes  of  amentia, 

147 
Picture  Test,  370 
Pierce,  Dr.  Bedford,  23 
Pigmentation  of  nerve  cells,  76 
Pituitary  glands,  administration  of,  in 

MongoUsm,  220,  401 
Plaskuda,  Dr.  W.,  35S 


Index 


487 


Play,   use  of,  in  training,    116,   408, 

413.  414 
Plumbism.     See  Lead 
Pneumonia  "  aspiration,"  403 

as  a  cause  of  death,  153 
Polio-encephalitis  of  Striimpell  as  a 

cause  of  amentia,  226 
Poor-Law    institutions,    aments    in, 

18.  435 
Porencephaly,  84,  243 

85  a  cause  of  amentia,  74 

double,  245 

in  primary  amentia,  223 

in  secondary  amentia,  243 

pseudo-,  84,  244 
Potential  criminals,  317 

lunatics,  187,  317 
Potentiality  of  cerebral  development, 

231 
Potts,  Dr.  W.  A.,  40,  43,  47,  48,  54, 

437,  451,  452 
PoweU,  Dr.  E.,  161 
Poynton,  Parsons  and  Holmes,  Drs., 

272,  274 
Pregnancy.     See  Gestation 
Premature  birth  as  a  cause  of  amen- 
tia, 25,  60 
synostosis  in  microcephalics,  203 
Pressure,  sense  of,  105 
Preyer,  W.,  103,  116 
Primary  amentia,  causation  of,  21 
clinical  varieties  of,  95 
comphcations  of,  220 
pathology  of,  73 
Primogeniture,  59 
Pringle,  Dr.,  146 
Progeny  of  aments,  451 
of  insane  mothers,  55 
of  neuropaths,  447 
Prognosis  in  amentia,  395  et  seq. 

due  to  cerebral  lesions,  233, 

397 
cretinism,  399 
epilepsy,  398 
hj-drocephalus,  338 
sclerosis,  398 
sense  deprivation,  399 
syphilis,  399 
in  microcephahcs,  397 
in  Mongolians,  397 
Pronunciation,  defects  of,  132.     See 

also  Speech 
Propagation  by  aments,  446 

prevention  of,  457 
Prostitutes,  332,  454 
Provision,  number  of  aments  in  need 
of,  in  England  and  Wales,  441 
nature  of,  required,  456 
Psychological  clinic,  360 
tests,  360  et  seq. 


Psychology,  experimental,  360 

of  amentia,  99  et  seq. 
Psychopathic  diathesis,  33 
Puberty,  mental  changes  accompany- 
ing, 176,  199 
retardation  of,  in  aments,  147 
in  cretins,  283,  286 
in  s}T)hilitic  aments,  268 
Pullen,  J.  H.,  the  case  of,  308 
Punishment,  effect  upon  aments,  422, 

423 
Purkinje's  cells,  260 

Quakers  and  intermarrying,  51 
Quatrefages,  44 

"  Rabbit  man,"  the,  210 

Rage,    attacks    of,    in    hypertrophic 

aments,  253,  258 
"  Raphael,  Der  Katzen-,"  304 
"  Rats,"  Shah  Daula's,  211 
Raviart,  Dr.,  48 
Reading,  teaching  of,  418 
Reasoning,  115 

cultivation  of,  348 

tests  for,  367 
Recall,  112 
Recidivism,  443 
Recurrences  in  insanity,  351 
Registrar-General,  292,  448 
Raid,  Dr.  A.,  23 
Religious  education,  420 

sense,  314 

in  aments,  123 
Remedial  measures,  454 
Rennert,  Dr.,  55 
Rentoul,  Dr.  R.  R.,  457 
ResponsibiUty,  conditions  of,  339 

of  aments,  337 
Retardation,  mental,  293,  382 
Retentiveness,  112 

tests  for,  365 
Reverie,  114 

Rewards,  use  of,  in  training,  422 
Ribot,  Dr.,  415 
Rickets  and  cretinism,  288 

and  hydrocephalus,  264 

as  a  cause  of  amentia,  62,  295 
Robinovitch,  Mdlle.,  59 
Roncoroni,  Professor,  77 
Rosanoff  and  Orr   36 
Ross,  Dr.,  245 
Rossi,  Dr.,  323 
Royal  Albert  Asylum,  435 
Riidin,  Dr.  E.,  42 
Rumination,  197 
Russell  and  Kingdon,  Drs.,  272-273 

Sabatier,  Dr.,  45 

Sachs,  Dr.,  86,  87,  272,  273 


488 


Index 


Sailer,  Dr.  J.,  260 
Sander,  Dr.,  205 
Sangford,  Mr.,  298 
Saulle,  Legrand  du,  56 
Savage,  Sir  G.  H.,  34,  277,  342 
SaviU,  Dr.  T.  D.,  47 
Sayer,  Dr.  Ettie,  42,  446 
Scalp  in  hydrocephalics,  264 

in  microcephalics,  207 
Scaphocephaly,  141 
Schaffer,  Dr.  K.,  273 
Scho.astic  acquirements  of  mentally 
defective  children,  167 
criterion  of  amentia,  2 
Scholz  and  Zingerle,  285 
Schools,  imbeciles  in,  439 
Littleton  House,  170 
special,    description   of   children 

attending,  168 
training,  409 
"  Scissor-legs,"  196 
Sclerosis,  79,  247 

cause  of,  81,  247,  257 
diffuse,  79,  247 
haemorrhage  in,  81 
hypertrophic,  nodular,  or  tuber- 
ous, 80,  255 
in  primary  amentia,  223,  224 
localized,  80,  247 
morbid  anatomy  of,  258 
pathology  of,  79 
Sclerotic  amentia,  247 
diffuse,  248 

atrophic  form,  248 
hypertrophic  form,  251 
nodular  or  tuberous,  255 
prognosis  in,  398 
Scott,  Dr.,  23 

Scouts,  Littleton  troop  of,  171 
Secondary  amentia,  causation  of,  37, 
226,  228,  229 
clinical  varieties  of,  95,  224 
pathology  of,  82 
prognosis  in,  396  et  seq. 
Segregation,  ,458 
Seguin,  Dr.  Edouard,  303,  307,   395, 

404,  414 
Sensation,  loi 

and  perception,  108 
cultivation  of,  406,  410 
defects  of,  102 
in   mentally   defective   children, 

164 
in  new-born,  102 
muscle,  tendon  and  joint,  106 
organic,  107 
Sense  deprivation,   amentia  due  to, 

295 
Senses,  four  chief,   in  normal  mind, 
122,  314 


Sentiment,  122 
Sex  of  aments,  17 

of  idiots  savants,  302 

of   mentally   defective   children, 
18 
Sexual  instincts,  107,  197,  322,  452 
Shah  Daula's  rats,  211 
Shelley,  brain  of,  206 
Sherlock,  Dr.,  23,  256 
Shock,  causing  amentia,  62 
Shuttleworth,  Dr.  G.,  48,  61,  149,  156, 
210,  219,   327,   398,  417,  464, 

465 
and  Beach,  Drs.,  40,  43,  47,  52, 
56 
Sichard,  Dr.,  323 
Siege  of  Paris,  56 
Simple  variety  of  amentia,  95 
Skeleton,  anomalies  of,  139,  143 
Skin,  anomahes  of,  146 
Skull    in     amentia,     87.      See     also 

Cranium 
Sleep  in  aments,  126 
Slums,    effect    of,    in    causation    of 

amentia,  38,  160 
Smalley,  Dr.,  23,  443,  444 
Smedley,  F.,  113 
Smell  in  aments,  103,  303 

tests  for,  363 
Smith,  Dr.  F.  J.,  271 
Smith,  Dr.  Hamblin,  423 
Sociology,  432 
Sollier,  Dr.,  90,  148 
Somatic  modifications,  21 

transmission  of,  29 
Speech,  128 

cultivation  of,  416 

in  aments,  130 

in  cretins,  286 

in  idiots,  198 

in  idiots  savants,  304 

in   mentally   defective   children, 

164 
in  savages,  133 
in  syphihtic  amentia,  268 
nervous  mechanism  of,  1 29 
retardation  of,  130,  382 
Spiegelberg,  Dr.,  58 
Spiller,  Dr.  W.  G.,  232 
Spinal  cord  in  amentia,  83 

in     disseminated     sclerosis, 

248 
in  microcephaly,  204,  209 
secondary  sclerosis  of,  260 
Spontaneous  variation,  27 
Sporadic  idiocy,  25 
Stammerers,  417 
Stature  of  aments,  143 
of  cretins,  286 
of  criminals,  322 


Index 


489 


stature  of  mentally  defective  chil- 
dren, 163 
of  microcephalics,  207 
Status  epilepticus,  258 
Stephen,    Sir    Fitzjames,    338,    339, 

340 
Sterility  in  cretins,  286 

in  idiots,   197 
Sterilization,  402,  457 
Stern,  Dr.,  366 
Stigmata  of  degeneracy,  137 
in  criminals,  322 
in  insane,  343 

in  mentally   defective   chil- 
dren, 162 
in  primary  aments,  138 
in   secondary   aments,   224, 

234 
Still-births  in  neuropaths,  448 
Stockard,  Dr.,  31 
Striimpell,  Professor,  81,  226 
Stupor  in  aments,  350 
Stutterers,  417 

Suicide  in  aments,  349,  350,  351 
Sullivan,  Dr.,  30,  31,  46 
Sumner,  Dr.,  32 

Sunstroke  as  a  cause  of  amentia,  61 
Supervision,  455 
Survival  of  lower  life  forms,  3 

of  man,  4 
Suspicion  in  aments,  234,  334 
Sutherland,  Dr.  G.  A.,  212,  215,  218, 

226,  289 
Synonyms,  foreign,  464 
Synostosis,     premature,     in     micro- 
cephaly, 203 
Syphilis  as  a  cause  of  amentia,   47, 
267,  269 
-    Mongolism,  212,  213 
Syphilitic  amentia,  267 

and  general  paralysis,  268 
description  of,  267 
diagnosis  of,  269 
illustrative  cases  of,  270 
prognosis  in,  270 

Talbot,  Dr.  E.,  142,  144,  147 
Talents,  special,  in  aments,  302 
Talipes  in  paralytic  aments,  234 
Taste,  102 

defects  of,  102 

tests  for,  363 
Tay,  Mr.  Waren,  272 
Tay-Sachs  disease,  273 
Taylor,  Dr.  F.  R.  P.,  249,  250 
Teeth,  anomalies  of,  143 
Telford-Smith,  Dr.,  211,  217 
Temperament  of  aments,  120 
Temperature,  appreciation  of,  106 

effect  of,  upon  aments,  149 


Tests,  mental,  359 

Aussage,  366 

Binet's  line,  366 

Binet  and  Simon's,  373 

Bourdon's  cancellation,  363 

card-sorting,  364 

completion     method      (Eb- 
binghaus),  368 

De  Sanctis',  376 

description  and  report,  365 

dissected  picture,  370 

for  association,  364 

for  attention,  363 

for  cutaneous  sensation,  363 

for  emotional  reaction,  367 

for  facility,  366 

for  general  capacity,  368 

for  hearing,  363 

for  intelligence,  368 

for  judgment,  367 

for  memory,  365 

for  movement,  371 

for  reasoning,  367 

for  retentiveness,  365 

for  smell,  363 

for  suggestibility,  366 

for  taste,  363 

for  vision,  362 

genus-species,  364 

graduated  serial,  372 

opposites,  364 

part-wholes,  364 

range  of  information,  369 
Thiemich,  Dr.,  103 
Thirst  in  aments,  107 
Thomas,  Dr.  C.  J.,  48,  135 
Thompson,  Dr.  J.  Bruce,  322 
Thomsen,  Dr.,  48 
Thomson,  Professor  J.  A.,  24 
Thomson,   Dr.   John,   127,   142,   216, 

284,  286,  289 
Thought,  114 

Thrombosis,  causing  amentia,  228 
Thymus  gland,  effect  of,  in  Mongol- 
ism, 220,  401 
Thyroid  gland,  administration  of,  in 
cretinism,  289 
in  Mongolism,  220,  401 

condition   of,    in   cretinism, 
282,  286 
secretion,  effect  of,  upon  brain, 
285 

temporary  arrest  of,  291 
Titchener,  Dr.  E.  B.,  361 
Tongue,  anomalies  of,  146 
in  Mongolism,  216 
sucking,  216 
tied,  131 
Touch,  sense  of,  loG 

cultivation  of,  411 


490 


Index 


Touch,  sense  of,  in  idiots  savants,  303 

painful,  412 
Townsend,  Miss  P.  D.,  170 
Toxic,    vascular    and    inflammatory 
amentia,  226  et  seq. 
causation  of,  226,  228 
clinical  symptoms,  226, 

229 
illustrative  cases  of,  236 
lesions  in,  235 
mental    characteristics, 

233 
prognosis  in,  233,  234, 

397 
Tracey,  Mr.  Justice,  337 
Tracheotomy,  necessity  for,  197 
Training,  400,  455 

effect    of,    in    amentia    due    to 
lesions,  232,  397 
sense  deprivation, 
296,  298 

general  principles  of,  403 

home,  408 

industrial,  419 

inteUigence,  415 

moral,  420 

of  movement,  412 

of  senses,  410 

of  speech,  416 

result  of,  399 

school,  409 

value  of,  455,  456 
Train-wrecking  by  aments,  330 
Transmission  of  neuropathic  diathe- 
sis, 36 
Trauma  as  a  cause  of  amentia,  56,  60, 

228,  238 
Treatment,  400 

in  cretinism,  288 

medical,  400 

surgical,  401 
Trelat,  Dr.,  306 
Tremor  in  amentia,  222,  235 

in  sclerosis,  249,  254,  257 

in  syphilitic  amentia,  268 
Tricks  and  habits,  126 

correction  of,  414 
Tuberculosis  as  a  cause  of  amentia, 

35,  47 
as  a  cause  of  death,  153 
effect  of,  upon  guinea-pigs,  32 

Tuke,  Dr.  Hack,  156 

Tumours  in  sclerotic  amentia,  256, 257 

Turgenieff,  brain  of,  206 

Turner,  Dr.  J.,  273 

Urinary  organs,  anomalies  of,  147 
Uterine    exhaustion    as    a    cause    of 
Mongolism,  213.     See  also  Gesta- 
tion 


Vagrancy,  440 
Vanity  in  aments,  192,  311 
Vaquez,  Dr.,  287 

Variation,  germinal,  23,  27,  30,  31, 
32 
pathological,  29,  33 
produced   by   environment, 

30,  32,  462 
spontaneous,  27 
Variations  in  mental  capacity,  i 
Varieties    of    primary    amentia,    95-, 
202 
of  secondary  amentia,  95,  224 
Vascular,    toxic,    and    inflammatory 

amentia.     See  Toxic 
Vessels  of  brain,  81,  82,  260 
Vision,  104 

cultivation  of,  411 
defects  of,  and  cortical  develop- 
ment, 295 
in  amaurotic  family  idiocy,  273 
in  amentia,  104 
in  hydrocephalus,  263 
in  idiots  savants,  303 
in  Mongohsm,  216 
in  new-born,  104 
in  syphilitic  amentia,  268 
tests  for,  362 
VitaUty  of  aments,  149 
Vogt,  Professor  C,  81,  203,  212,  256, 

273 
Voisin,  Dr.  Felix,  205 
Voisin,  Dr.   Jules,  42,  50,   104,   148, 

303 
Vohtion,  117,  317,  318,  323,  331,  338, 

340.  453 

Wages  earned  by  aments,  435 

Walking,  age  at,  in  aments,  148 

Warner,  Dr.  Francis,  123,  128,  156, 
412,  414 

Wassermann  reaction,  48,  213,  257, 
267,  274 

Watson,  Dr.  G.,  32,  206,  269 

Webster,  brain  of,  206 

Weeks  and  Davenport,  Drs.,  36 

Weight  of  brain.     See  Brain 

Weismann,  Professor,  29,  30 

Wey,  Dr.  H.,  322 

Whipple,  Dr.  G.  M.,  361,  365 

Whooping-cough  as  a  cause  of  amen- 
tia, 229 

Wiglesworth,  Dr.,  45 

Wilbur,  Dr.,  209 

Wilder,  Dr.,  206 

Wilkinson,  Mr.  F.,  23 

Will.     See  Vohtion 

Wilmarth,  Dr.,  79,  214 

Wilms,  Professor,  282 

Wilson,  Dr.  G.,  322 


Index 


491 


Wilson,  Dr.  P.,  23,  325 
Winder,  Dr.,  445 
Windle,  Professor,  55 
Winslow,  Dr.  Forbes,  306 
Witnesses,  aments  as,  341 
Witzmann,  Dr.,  305 
Wizel,  Dr.,  307 
Woodwark,  Dr.  A.  S.,  401 
Word-blindness    and    word-deafness, 
134 


See 


Work,  capacity  of  aments  for. 

Employment 
Work,  Dr.  H.,  447 
Workhouses,  feeble-minded  in,  436 
idiots  and  imbeciles  in,  439 
maternity  wards,  aments  in,  451 
Writing,  teaching  of,  418 
WyUie,  Dr.,  132 

Ziegler,  Professor,  74,  83 


THE  END 


Bailliire,  Tindall  &'  Cox,  8  Henrietta  Street,  Covettt  Garden 


PRESS  NOTICES  OF  THE  FIRST  EDITION 


"...  We  can  strongly  recommend  this  book,  not  only  as  an  interesting 
study  in  amentia,  but  also  as  a  work  throwing  considerable  light  on  social 
problems  of  vast  consequence.   .  .  ." — Lancet,  March  z^,  igog. 

"...  Dr.  Tredgold  has  made  a  very  comprehensive  survey  of  his  subject, 
more  especially  from  the  scientific  and  social  sides.  We  are  glad  to  have 
the  valuable  research  work  of  the  author  gathered  together  in  a  convenient 
volume  which  is  easy  of  reference,  and  which  will  be  found  most  helpful  to 
those  wishing  to  gain  an  insight  into  the  complicated  problems  of  mental 
defect.  .   .   ." — British  Medical  Journal,  March,  igog. 

"...  Dr.  Tredgold's  work  is  admirable  in  every  respect.  It  is  founded 
on  thorough  knowledge  of  its  important  subject,  in  its  pathological,  socio- 
logical, and  clinical  aspects;  and  it  imparts  the  result  of  his  wide  experience 
and  knowledge  of  hterature  in  a  clear,  sensible,  and  interesting  way.  .  .  ." — 
Edinburgh  Medical  Journal,  January,  1909. 

"...  This  is  a  valuable  and  interesting  book,  not  only  to  the  alienist 
physician  and  the  general  practitioner,  but  also  to  the  statesman  and  all 
interested  in  sociological  questions.  .  .  ." — Indian  Medical  Gazette,  January, 
1909. 

"...  This  is  a  notable  and  opportune  volume,  which  should  be  studied 
by  all  students  of  inebriety  and  everyone  interested  in,  or  concerned  with, 
the  care  of  mentally  defective  children  and  adults.  It  meets  a  very  distinct 
want  in  our  medico-sociological  literature,  and  should  become  the  authoritative 
work  on  mental  deficiency.  It  is  scientific  in  its  scope,  arrangement,  and 
presentation,  thoroughly  practical  in  its  aims,  and  marked  by  a  grace  and 
dignity  of  style  which  will  render  it  acceptable  to  both  speciahsts  and  in- 
telligent laymen.   .  .  ." — British  Journal  of  Inebriety,  January,  1909. 

"...  The  results  of  the  author's  investigations  regarding  the  aetiology  of 
amentia  cannot  be  too  widely  known,  nor  can  the  necessity  that  obviously 
exists  for  measures  to  prevent  its  propagation.  .  .  ." — Glasgow  Medical  Journal, 
May,  1909. 

"...  Dr.  Tredgold  has  contributed  an  excellent  addition  to  the  literature 
dealing  with  mental  deficiency  ...  he  is  well  qualified  to  write  upon  this 
subject,  and  has  accumulated  abundant  and  valuable  material  based  upon 
personal  research.   .   .   ." — Bristol  Medico-Chirurgical  Journal,  June,  1909. 


PRESS  NOTICES— Continued 

"...  This  volume  is  well  worth  the  study,  not  only  of  professional  men, 
but  also  of  ordinary  laymen  in  any  way  interested  in  the  question  of  mental 
deficiency.  .  .  ." — Scotsman,  September  21,  1908. 

"...  The  luminous  statement  of  the  author  in  regard  to  the  difficult 
question  of  the  criminal  responsibihty  of  aments  affords  an  excellent  example 
of  the  lucid  manner  in  which  the  book  is  written,  and  the  wealth  of  illustra- 
tive cases  which  are  to  be  found  in  its  pages  render  the  publication  an 
admirable  exposition  of  one  of  the  most  difficult  fields  of  study  in  medical 
science.  .  .   ." — Clinical  Journal,  May  9,  1909. 

"...  Dr.  Tredgold  is  a  recognized  authority  of  eminence  on  this  subject. 
.  .  .  His  work,  as  was  to  be  expected,  is  a  learned,  scientific,  and  com.pre- 
hensive  treatise.  It  is  probably  the  best  book  in  the  language  on  the 
subject.  .  .  ." — Canadian  Nurse,  March,  1909. 

"...  As  might  be  expected  from  the  pen  of  Dr.  Tredgold,  the  whole  subject 
matter  has  been  gone  into  in  a  thoroughly  careful  and  exhaustive  manner, 
the  result  being  an  interesting  book  brought  up  to  date,  which  should  be  found 
in  the  hbrary  of  everyone  connected  with,  or  interested  in,  that  section  of 
mental  infirmity.  .  .  ." — Asylum  News,  October  15,  1908. 

"...  Dr.  Tredgold  has  spent  many  years  upon  this  subject  without  allowing 
his  mind  to  be  cramped  by  fidelity  to  prejudice  or  conceived  ideas  ...  he  brings 
to  his  examination  of  data  a  thorough-going  earnestness  and  a  broad-minded 
freedom  from  prejudice  which  are  beyond  all  praise.  .  .  ." — Bristol  Daily 
Mercury,  November  7,  1908. 

"...  It  is  based  upon  an  enormous  amount  of  material  collected  by  the 
author  from  very  diSerent  sources  in  the  last  ten  years.  This  is  so  skilfully 
handled  and  so  well  classified  that  the  book  is  always  clear  and  interesting 
...  it  contains  an  admirable  essay  on  the  relation  of  the  ament  to  society, 
and  an  account  of  morally-defective,  criminal,  and  insane  aments  which  will 
be  of  the  greatest  possible  use  in  many  difficult  medico-legal  cases.  .  .  ," — 
Review  of  Neurology  and  Psychiatry,  January,  1909. 

"...  It  is  a  compendious  mass  of  most  useful  material  for  the  inspiration 
of  the  student  interested  in  the  various  phases  of  mental  unsoundness.  ..." 
— Guy's  Hospital  Gazette,  December  12,  1908. 

"...  There  can  be  no  doubt  that  it  will  be  generally  regarded  as  indis- 
pensable as  a  trustworthy  guide  to  the  most  recent  scientific  and  sociological 
findings  in  this  department  of  humane  activity  .  .  .  should  be  read  and  referred 
to  by  all  who  are  called  into  relation  with  the  mentally  defective.  .  .  ." — - 
Journal  of  Mental  Science,  July,  1909. 

"...  It  may  at  once  be  said  that  the  book  constitutes,  perhaps,  the  best 
textbook  on  the  subject  in  the  EngUsh  language.  .  .  ." — Medical  Press, 
July  28,  1909. 


SOME  OTHER  PUBLICATIONS  BY  THE  AUTHOR 


"  Variations  of  Ribs  in  the  Primates,"  Journal  of  Anatomy  and  Physiology, 
vol.  xxxi. 

"  Three  Dissimilar  Cases  of  Multiple  Lesions  of  the  Central  Nervous 
System,"  Mott's  Archives  of  Neurology,  vol.  i.,  1899. 

"  Hemiatrophy  of  the  Brain,  and  its  Results  on  the  Cerebellum,  Medulla, 
and  Spinal  Cord"  (in  conjunction  with  F.  W.  Mott,  M.D.,  F.R.S.),  Brain, 
part  xc,  1900. 

"  Primary  Degeneration  of  the  Motor  Tract  "  (in  conjunction  with  F.  W. 
Mott,  M.D.,  F.R.S.),  Brain,  part  c,  1902. 

"  Hypertrophy  of  the  Brain,"  Quain's  Dictionary  of  Medicine,  1902. 

"  The  Subsequent  History  of  Children  born  during  Insanity  of  the  Mother," 
Lancet,  May  17,  1902. 

"  Amentia:  Its  Causes,  Classification,  and  Pathology,"  Mott's  Archives  of 
Neurology,  vol.  ii.,  1903. 

"  Insanity  in  Imbeciles,"  Journal  of  Mental  Science,  January,  1903. 

"  Amentia,"  Practitioner,  September,  1903. 

"  Disseminated  Sclerosis,"  Review  of  Neurology  and  Psychiatry,  July,  1904. 

"  On  the  Relations  of  Epilepsy  to  Amentia,"  British  Journal  of  Children's 
Diseases,  July,  1904. 

"  The  Problem  of  the  Feeble-Minded,  with  Especial  Reference  to  the  Legal 
Powers  for  their  Training  and  Detention  "  (address  at  the  Guildhall  Confer- 
ence, October  14,  1904),  Charity  Organization  Review,  November,  1904. 

"  Special  Training  Considered  from  the  Physiological  Standpoint  "  (address 
to  teachers  of  the  National  Special  Schools  Union,  July  i,  1905).  British 
Journal  of  Children's  Diseases,  October,  1905. 

"  The  Varieties  of  the  Feeble  Mind  "  (address  at  the  Conference  of  After- 
Care  Committees,  Nottingham,  October  12,  1905). 

"  Report  on  the  Number  and  Condition  of  the  Mentally  Deficient  (including 
Epileptics)  in  Somersetshire  "  (presented  to  the  Royal  Commission  on  the 
Feeble-Minded,  December  31,  1905). 

"  The  Feeble-Minded  and  Society  "  (address  at  the  Mansion  House,  May 
13,  1909),  Eugenics  Review,  July,  1909. 

"  Some  Account  of  the  Report  and  Recommendations  of  the  Royal  Com- 
mission on  the  Feeble-Minded  "  (address  at  the  Worcester  Conference  of 
Charity  Organization  Societies,  June  8,  1909),  Charity  Organization  Review, 
July,  1909. 


OTHER  FJJBLICATIO^S— Continued. 

"  A  Lecture  on  Feeble-Minded  Children,"  delivered  at  the  MedicalGraduates' 
College,  London,  July  7,  1909,  Medical  Press  and  Circular,  August  25,  1909. 

"  Mentally   Defective   Children,"   in   Kelynack's  Medical  Examination   of 
Schools  and  Scholars,  1910.  . 

"  The  Feeble-Minded  Child,"  Journal  of  the  Royal  Sanitary  Institute,  vol, 
xxxii..  No.  2,  191 1. 

"  Neurasthenia  and  Insanity,"  Practitioner,  January,  191 1. 

"  The  Mentally  Deficient  Child,"  The  Child,  January,  191 1. 

"  Eugenics  and  Future  Human  Progress,"  Eugenics  Review,  July,  1911. 

"  Heredity-  in  Relation  to  Mental  Deficiency,"  National  Conference  on  the 
Prevention  of  Destitution,  191 1. 

"  Dull  and  Backward  Children,"  British  Journal  of  Children's  Diseases, 
October,  191 1. 

"  Marriage  Regulation  and  National  Family  Records,"  Eugenics  Review, 
April;  1912.' 

"  Some  Medical  Aspects  of  Eugenics,"  Medical  Press,  July  31  and  August  7, 
1912. 

"  Eugenics,"  Quarterly  Review,  July,  1912. 

"  Heredity  and  Environment  in  regard  to  Social  Reform,"  Quarterly  Review, 
October,  191 3. 


COLUMBIA  UNIVERSITY  LI^ARIES 

This  book  is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing, 
as  provided  by  the  rules  of  the  Library  or  by  special  ar- 
rangement with  the  Librarian  in  charge. 

DATE  BORROWED 

DATE  DUE 

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